FORM 1-SCC

Page (pahina) 1

REPUBLIC OF THE PHILIPPINES

MUNICIPAL TRIAL COURT
THIRD JUDICIAL REGION
Guiguinto, Bulacan

Ligas Kooperatiba ng Bayan Sa Pagpapaunlad

Represented by Jocelyn J. Mapoy,
Plaintiff,

vs. Small Claims Case No. __________

For: _Sum of Money____________

GREGORIO C. SANTIAGO
Defendant,

x-------------------------------------------x

STATEMENT OF CLAIM
(HABLA NG PAGSINGIL)

1. The personal circumstances of the parties are as follows :

( ang bawat panig ay ang mga sumusunod)

Ligas Kooperatiba ng Bayan

sa Pagpapaunlad__________ N/A N/A N/A
NAME OF PLAINTIFF/S SEX AGE CIVIL STATUS
(Pangalan ng Naghahabla) (Kasarian) (Edad) (Katayuang Sibil)

(Put a check on any of the following)

(Pumili sa mga sumusunod at lagyan ng tsek)

INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidwal) (Korporasyon) (Bakasan)

X
COOPERATIVE SOLE PROPRIETORSHIP
(Kooperatiba) (Solong Pagmamay-ari)

HOME ADDRESS: (CITY) LKBP Tower Cagayan Valley Rd., Sta. Rita, Gto., 3015
(Pahatirang Sulat sa Bahay)) (Lungsod) Zip Code

(Province, if applicable) ________ Bulacan______________ ___N.A._

(Lalawigan, kung meron) Zip Code

Telephone No.___(044) 794-2912________ Cellphone No. _________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK : LKBP Tower Cagayan Valley Rd., Sta. Rita, Gto., Bulacan
(Lugar ng Pinagtatrabuhan)
FORM 1-SCC
Page (pahina) 2

NAME OF REPRESENTATIVE, if applicable __ Jocelyn J. Mapoy______

(Pangalan ng Kinatawan, kung meron)

HOME ADDRESS: (City) Rocka Village Sta. Rita, Guiguinto, 3015

(Pahatirang sulat sa Bahay) (Lungsod) Zip Code

(Province, if applicable) ________Bulacan_____________________ ___3015_

(Lalawigan, kung meron ) Zip Code

Telephone No. (044) 794-2912 Cellphone No. 09228321526

(Telepono Blg.) (Selpon Blg.)

GREGORIO C. SANTIAGO M 62 Married

NAME OF DEFENDANT/S SEX AGE CIVIL STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayuang Sibil)

(Put a check on any of the following)

(Pumili sa mga sumusunod at lagyan ng tsek)

X INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidwal) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari)

HOME ADDRESS: (CITY) #186 Sta. Cruz, Guiguinto, Bulacan 3015

(Pahatirang Sulat sa Bahay) (Lungsod) Zip Code

(Province, if applicable) _________Bulacan______ _3015___

(Lalawigan, kung meron) Zip Code

Telephone No. 690-0677 Cellphone No. _ ___

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK #186 Sta. Cruz, Guiguinto, Bulacan____________

(Lugar ng Pinagtatrabuhan)

NAME OF REPRESENTATIVE, if applicable _________________________________

(Pangalan ng Kinatawan, kung meron)

HOME ADDRESS: (City) ________________________________ ________

(Pahatirang sulat sa Bahay)(Lungsod) Zip Code

(Province, if applicable) ____________________________________ _______

(Lalawigan, kung meron ) Zip Code

Telephone No. _______________________ Cellphone No. ________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK _______________________________________________________

(Lugar ng Pinagtatrabuhan)

Telephone No. _______________________ Cellphone No. _________

(Telepono Blg.) (Selpon Blg.)
FORM 1-SCC
Page (pahina) 3

If more than one (1) defendant, list next defendant here:

(Kung higit sa isa (1) ang Hinahabla, ilagay ang susunod na hinahabla rito:)

___________________ ___ ___ _________

NAME OF DEFENDANT/S SEX AGE CIVIL STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayuang Sibil)

(Put a check on any of the following)

(Pumili sa mga sumusunod at lagyan ng tsek)

INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidwal) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari)

HOME ADDRESS: (CITY) ____________________________ ______

(Pahatirang Sulat sa Bahay)) (Lungsod) Zip Code

(Province, if applicable) __________________ _________

(Lalawigan, kung meron) Zip Code

Telephone No. ____________________ Cellphone No. _________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK ______________________________________________________

(Lugar ng Pinagtatrabuhan)

NAME OF REPRESENTATIVE, if applicable _________________________________

(Pangalan ng Kinatawan, kung meron)

HOME ADDRESS: (City) ________________________________ ________

(Pahatirang sulat sa Bahay) (Lungsod) Zip Code

(Province, if applicable) ____________________________________ _______

(Lalawigan, kung meron ) Zip Code

Telephone No. _______________________ Cellphone No. ________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK _______________________________________________________

(Lugar ng Pinagtatrabuhan)

Telephone No. _______________________ Cellphone No. _________

(Telepono Blg.) (Selpon Blg.)

*Note: If you need space, you can write at the back of this Form.
(*Tala: Kung Kailangan mo ng karagdagang patlang, maari mong isulat sa likod ng
Form na ito.)
FORM 1-SCC
Page (pahina) 3

If more than one (1) defendant, list next defendant here:

(Kung higit sa isa (1) ang Hinahabla, ilagay ang susunod na hinahabla rito:)

___________________ ___ ___ __________

NAME OF DEFENDANT/S SEX AGE CIVIL STATUS
(Pangalan ng Hinahabla) (Kasarian) (Edad) (Katayuang Sibil)

(Put a check on any of the following)

(Pumili sa mga sumusunod at lagyan ng tsek)

INDIVIDUAL CORPORATION PARTNERSHIP

(Tao/Indibidwal) (Korporasyon) (Bakasan)

COOPERATIVE SOLE PROPRIETORSHIP

(Kooperatiba) (Solong Pagmamay-ari)

HOME ADDRESS: (CITY) ________________________ _____

(Pahatirang Sulat sa Bahay)) (Lungsod) Zip Code

(Province, if applicable) ______________ ____

(Lalawigan, kung meron) Zip Code

Telephone No. _____________________ Cellphone No._____________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK _________________________________________

(Lugar ng Pinagtatrabuhan)

NAME OF REPRESENTATIVE, if applicable _________________________________

(Pangalan ng Kinatawan, kung meron)

HOME ADDRESS: (City) ________________________________ ________

(Pahatirang sulat sa Bahay)(Lungsod) Zip Code

(Province, if applicable) ____________________________________ _______

(Lalawigan, kung meron ) Zip Code

Telephone No. _______________________ Cellphone No. ________________

(Telepono Blg.) (Selpon Blg.)

PLACE OF WORK _______________________________________________________

(Lugar ng Pinagtatrabuhan)

Telephone No. _______________________ Cellphone No. _________

(Telepono Blg.) (Selpon Blg.)

*Note: If you need space, you can write at the back of this Form.
(*Tala: Kung Kailangan mo ng karagdagang patlang, maari mong isulat sa likod ng
Form na ito.)
 FORM 1-SCC
Page (pahina) 4

FOR OFFICIAL USE ONLY

(Para sa Opisyal na gamit lamang)
To be accomplished by the Branch Clerk of Court
(Sasagutan ng Kawani ng Hukuman)
2. Plaintiff claims the defendant owes 1. Cause of Action
P 48,173.85
(Ang Hinahabla ay umutang sa Naghahabla Check
Ng halagang P48,173.85) Promissory Note
Contract
(a) Why does the defendant owe plaintiff Oral Written
Money?
(Bakit ang Hinahabla ay nagkautang ng Barangay Agreement
Salapi sa Naghahabla?) Injuries
As a member of LKBP Cooperative Accidental Intentional
he seek financial assistance to finance
his business. Damage to Property
Other (Please specify)
(If you need more space, please use the back page). ___________________________)
(Kung kailangan mo ng karagdagang patlang,
Maaring gamitin ang likod ng pahinang ito.) 2. _____ Barangay conciliation
required.
(b) When did this happen? Kailan ito nangyari? If yes, _____ Certificate to File
Date: March 27, 2009 Action
(Petsa) _____ Compromise
Agreement attached.
If no specific date, give the time period: ______ Barangay conciliation not
(Kung walang tiyak na petsa, ibigay ang required. Please state the reason )
Tantiyang panahon) ______________________________
Date Started: ___________
(Petsa nagsimula)
Through: ____________

(c) How did you compute the money owed to you? ( Do not include court costs or
fees) Loan amount x 18% int. (Add-on) PA, other charges deducted on the loan
amount.
(Paano mo kinuwenta ang salaping inutang sa iyo?) (Hindi kasama ang bayad sa
pagpapatala sa hukuman.)

3.(a) Did you ask the defendant to pay you before you filed this case?
(Siningil mo ba ang Hinahabla bago ka nagsampa ng kasong ito)

X Yes No
(Oo) (Hindi)

If no, explain: ____________________________________________________________

(Kung hindi, ipaliwanag)
FORM 1-SCC
Page (pahina) 5

(b) How did you ask the defendant?

(Paano mo siningil ang Hinahabla)
X In person By Phone
(Sa kanya mismo) (Sa telepono)
X In writing (others (please specify)
(Sa sulat) (Iba pa) (Pakisulat kung paano)
( c) When did you do this? August 25, 2015
(Kailan mo ginawa ito)
4. What is your proof that defendant owes you money? Promissory Note signed by the
defendants.
(Ano ang iyong katibayan o pruweba na ang Hinahabla ay may utang na salapi sa
iyo?) Katibayan Sa Pag-utang at pangako sa Pagbabayad na Pirmado ng nahahabla.
5. Did you attach your proof to this form?
(Iyo bang inilakip ang katibayan o pruweba sa Form na ito?

X Yes No
(Oo) (Hindi)
6.Was this claim referred to the barangay?
(Dumaan ba sa barangay ang paniningil na ito)

Yes No X Not Covered

(Oo) (Hindi) (Hindi sakop)
State reason:
(Isulat ang dahilan)
We’re an Institution
If yes, do you have a Certificate to File Action or a Compromise Agreement executed
before the barangay? __________________.
(Kung oo, meron ka bang Patunay sa Pagsampa ng Kaso o Kasunduan na isinagawa sa
barangay?)

6-A. In this court station, how many small claims have you filed within this
calendar year prior to this present case. __ 1st_________
(Sa court station na ito, pang ilang kaso na itong isinampa mo sa loob ng
kasalukuyang taon?) _______________.
7. By the filing of this action, plaintiff hereby waives any amount in excess of
P100,000.00, excluding interest and costs.
(Sa pagsampa ng kasong ito, ang Naghahabla ay isinusuko ang anumang halaga na
higit sa P100,000.00, hindi kasama ang tubo at gastos sa pagsampa ng kasong ito.)

PRAY E R
(PAGSAMO)

WHEREFORE, plaintiff respectfully prays for judgment ordering defendant

to pay the amount of P 48,173.85 plus the interest at the rate of 12% per annum / per
month from March 28, 2011 up to July 27, 2015 amounting to P 39,217.49 and penalties
amounting to P83,534.98 from March 28, 2011 to July 27, 2015, plus the litigation
expenses incurred in processing of his account.
(DAHIL DITO, ang Naghahabla ay magalang na sumasamo na igawad ang
kapasiyahang utusan ang Hinahabla na magbayad sa Naghahabla ng halagang
P48,173.85 pati ang tubo na 12% bawat taon / buwan simula Marso 28 2011 hanggang
Hulyo 27, 2015 na nagkakahalaga ng P39,217.49 at multa na nagkakahalaga ng
P83,534.98 mula Marso 28, 2011 hanggang Hulyo 27, 2015, kasama ang lahat ng legal
na gastusin sa pagsasampa sa korte ng kanyang kaso.)

____ Guiguinto, Bulacan______, ____________, 2015.

PLACE WHERE FILED
(Lugar kung saan inihain)
__JOCELYN J. MAPOY__
PLAINTIFF
(Naghahabla)
FORM 1-ABP22-SCC

VEREFICATION AND CERTIFICATION OF NON-FORUM SHOPPING

I, __JOCELYN J. MAPOY__, of legal age, __FILIPINO___, __married___

(name) (citizenship) (civil status)

and a resident of Sta. Rita, Guiguinto, Bulacan, on oath, state :

(address)

1. That I am the representative of the Plaintiff in the above-entitled case have

caused this Statement of Claim to be prepared; that I read and understood
its contents which are true and correct of my own personal knowledge
and/or based on true records;

2. That I have not commenced any action or proceeding involving the same
issue and specifically the same check/s in the Supreme Court, the Court of
Appeals or any other tribunal or agency, particularly before the Office of
the Provincial Prosecutor of Guiguinto ; that to the best of my knowledge,
no such action of proceeding is pending in the Supreme Court, the Court
of Appeals or any other tribunal or agency, and that, if I should learn
thereafter that a similar action or proceeding has been filed or is pending
before these courts or tribunal or agency, I undertake to report that fact to
the Court within five (5) days therefrom.

3. That I knowingly and voluntarily waive and forego the institution of

any criminal complaint for Violation of Batas Pambansa Blg. 22
against the defendant herein based on the same check/s subject matter
of this Small Claims Complaint.

IN WITNESS WHEREOF, I have hereunto set my hand this _____ day of

__________, 20___.

_JOCELYN J. MAPOY_
AFFIANT
Driver’s License No. CO7-07-018454
Guiguinto, Bulacan: 09/27/2013

SUBSCRIBED AND SWORN to before me this ________ day of _________,

20___.

NOTARY PUBLIC

Doc. No. _________

Page No. _________
Book No. _________
Series of __________
REPUBLIC OF THE PHILIPPINES)
GUIGUINTO, BULACAN ) S.S

AFFIDAVIT

I, JOCELYN J. MAPOY, Filipino, of legal age, married with postal address at

Sta. Rita, Guiguinto, Bulacan, after being duly sworn according to law, hereby state:

1. That I am the Asset & Management Group Head of “Ligas Kooperatiba ng

Bayan sa Pagpapaunlad” (LKBP). A duly organized cooperative with
principal address at Sta. Rita, Guiguinto, Bulacan;

2. That in Board Resolution No.2013-133, dated September 16, 2013, as

shown by herein attached Secretary Certificate marked as ANNEX _A_ I
am authorized to file the appropriate civil and/or criminal cases against
delinquent members/borrowers of our Cooperative.

3. That I am suing Gregorio C. Santiago of N0. 186 Sta. Cruz, Guiguinto,

Bulacan for failure to complied in his Loan Contract. Wherein the Loan
term is already matured and there’s still a remaining balance, and he
always make promises he can’t fulfilled.

4. That despite oral & written demands, the last of which is attached hereof
as Annex __B___, Demand Letter, dated August 25 2015, the said person
until now failed to settle his loan obligation; and

5. That I am executing this affidavit to attest to the truth of the foregoing

facts and purpose of filing a case for “Small Claim” against Gregorio C.
Santiago.

IN WITNESS WHEREOF, I have signed this ____day of _______, 2015 at

_____________, Bulacan

JOCELYN J. MAPOY
Complainant

SUBSCRIBED AND SWORN to before me this _____day of ______, 2015 at

_____in ___________, Bulacan, affiant exhibiting to me her Driver’s License No. CO7-
07-018454, as competent proof of her identity.

Doc. No. ___

Page No. ___ Notary Public
Book No. ___
Series of 20__