FORM 1-SCC

Page (pahina) 1
REPUBLIC OF THE PHILIPPINES
MUNICIPAL TRIAL COURT IN CITIES
ILOILO CITY
Iloilo Finance Corporation,
Plaintiff,
vs.

Civil Case No. _______________

For: Collection of Money

William Dungog, Georgie C. Floro

and Joseph C. Areo,
Defendants.
x - - - - - - - - - - - - - - - - - - - - - - - - - - - -x

THIS FORM IS NOT FOR SALE

AND MAY BE REPRODUCED
(Ang FORM na ito ay LIBRE at maaaring kopyahin)
STATEMENT OF CLAIM
(HABLA NG PAGSINGIL)
1. The personal circumstances of the parties are as follows:
(Ang bawat panig ay ang mga sumusunod)
ILOILO FINANCE CORPORATION
NAME OF PLAINTIFF/S
STATUS
(Pangalan ng Naghahabla)
(Katayuang Sibil)

________
SEX

_______
AGE

(Kasarian)

________
CIVIL

(Edad)

(Put a check on any of the following)

(Pumili sa mga sumusunod at lagyan ng tsek)

[]

[/]

INDIVIDUAL

(Tao/Indibidwal)

[]

CORPORATION

PARTNERSHIP

(Korporasyon)

[ ]COOPERATIVE
(Kooperatiba)

(Bakasan)

[]

SOLE PROPRIETORSHIP
(Solong Pagmamay-ari)

HOME ADDRESS: (City) __________________________

Pahatirang Sulat sa Bahay) [Lungsod]
Zip Code

_________

(Province, if applicable)______________________________

________

Zip

(Lalawigan, kung meron)

Code
Telephone No. _3375652, 3375360
(Telepono Blg.)

Cellphone No. _______________

(Selpon Blg.)

PLACE OF WORK : ILOILO FINANCE CORP., C. YOUNG BLDG. SOLIS ST.,

ILOILO CITY
(Lugar ng Pinagtatrabahuhan)
FORM 1-SCC
Page (pahina) 2
NAME OF REPRESENTATIVE, if applicable ARLENE L. LOCSIN
(Pangalan ng Kinatawan, kung meron)
HOME ADDRESS:

(City) c/o Iloilo Finance Corporation, C. Young Bldg.

Solis St., Iloilo City
5000 (Pahatirang Sulat sa Bahay) [Lungsod]
Zip Code
(Province, if applicable)______________________________
________
(Lalawigan, kung meron)
Zip Code
Telephone No. 3375652, 3375360
_______________
(Telepono Blg.)
WILLIAM DUNGOG
NAME OF DEFENDANT/S
STATUS
(Pangalan ng Hinahabla)
(Katayuang Sibil)

[/]

INDIVIDUAL
(Tao/Indibidwal)
(Bakasan)

Cellphone No.
(Selpon Blg.)

_____
SEX
(Kasarian)

[]CORPORATION

______________
AGE
CIVIL
(Edad)

[]PARTNERSHIP

(Korporasyon)

[]COOPERATIVE
(Kooperatiba)

[]

SOLE PROPRIETORSHIP
(Solong Pagmamay-ari)

HOME ADDRESS:
(City) _________________________________________
________
(Pahatirang Sulat sa Bahay) [Lungsod]
Code

Zip

5020

(Province, if applicable)Florvel Homes, Buray, Oton, Iloilo

Zip

(Lalawigan, kung meron)

Code

Telephone No. ______________________Cellphone No. _______________

(Telepono Blg.)
(Selpon Blg.)
PLACE OF WORK __________________________________________________________
(Lugar ng Pinagtatrabahuhan)
NAME OF REPRESENTATIVE, if applicable_________________________________
(Pangalan ng Kinatawan, kung meron)
HOME ADDRESS:
(City) ________________________________________
________
(Pahatirang Sulat sa Bahay) [Lungsod]
Code
(Province, if applicable)______________________________
(Lalawigan, kung meron)

Zip

________
Zip

Code

Telephone No. ______________________Cellphone No. _______________

(Telepono Blg.)
(Selpon Blg.)
PLACE OF WORK __________________________________________________________
(Lugar ng Pinagtatrabahuhan)
Telephone No. ______________________Cellphone No.
_________________
(Telepono Blg.)
(Selpon Blg.)
If more than one (1) defendant, list next defendant here:
(Kung higit sa isa (1) ang Hinahabla, ilagay ang susunod na
hinahabla
rito:)
FORM 1-SCC
Page (pahina) 3
GEORGIE C. FLORO
NAME OF DEFENDANT/S
CIVIL STATUS
(Pangalan ng Hinahabla)
(Katayuang Sibil)

__M___

[/]

[]CORPORATION

INDIVIDUAL

(Tao/Indibidwal)

[]

____
SEX

__________
AGE

(Kasarian) (Edad)

PARTNERSHIP
(Korporasyon)

(Bakasan)

[]

COOPERATIVE
(Kooperatiba)

[]

SOLE PROPRIETORSHIP
(Solong Pagmamay-ari)

HOME ADDRESS: (City)_________________________________

(Pahatirang Sulat sa Bahay) [Lungsod]
Code

________
Zip

(Province, if applicable) Florvel Homes, Buray, Oton

5020
Zip

(Lalawigan, kung meron)

Code
Telephone No. ______________________Cellphone No. _______________
(Telepono Blg.)
(Selpon Blg.)

PLACE OF WORK __________________________________________________________

(Lugar ng Pinagtatrabahuhan)
NAME OF REPRESENTATIVE, if
applicable_____________________________________
(Pangalan ng Kinatawan, kung meron)
HOME ADDRESS:
(City) ________________________________________
________
(Pahatirang Sulat sa Bahay) [Lungsod]
Code
(Province, if applicable)______________________________
(Lalawigan, kung meron)
Code

Zip

________
Zip

Telephone No. ______________________Cellphone No. _______________

(Telepono Blg.)
(Selpon Blg.)
PLACE OF WORK __________________________________________________________
(Lugar ng Pinagtatrabahuhan)
Telephone No. ______________________Cellphone No. _______________
(Telepono Blg.)
(Selpon Blg.)

JOSEPH C. AREO______
______________
NAME OF DEFENDANT/S
STATUS
(Pangalan ng Hinahabla)
(Katayuang Sibil)

M__
SEX

____
AGE
(Kasarian) (Edad)

CIVIL

[/]

[]CORPORATION

INDIVIDUAL

[]

PARTNERSHIP

(Tao/Indibidwal)

[]

COOPERATIVE
(Kooperatiba)

(Korporasyon)

[]

(Bakasan)

SOLE PROPRIETORSHIP
(Solong Pagmamay-ari)

HOME ADDRESS: (City) Magsaysay Village, Lapaz, Iloilo City

(Pahatirang Sulat sa Bahay) [Lungsod]
Code
(Province, if applicable) _______________________

5000
Zip

________
Zip

(Lalawigan, kung meron)

Code
Telephone No. ______________________Cellphone No. _______________
(Telepono Blg.)
(Selpon Blg.)

PLACE OF WORK __________________________________________________________

(Lugar ng Pinagtatrabahuhan)
NAME OF REPRESENTATIVE, if
applicable_____________________________________
(Pangalan ng Kinatawan, kung meron)
HOME ADDRESS:
(City) ________________________________________
________
(Pahatirang Sulat sa Bahay) [Lungsod]
Code
(Province, if applicable)______________________________
(Lalawigan, kung meron)
Code

Zip

________
Zip

Telephone No. ______________________Cellphone No. _______________

(Telepono Blg.)
(Selpon Blg.)
PLACE OF WORK __________________________________________________________
(Lugar ng Pinagtatrabahuhan)
Telephone No. ______________________Cellphone No. _______________
(Telepono Blg.)
(Selpon Blg.)
*Note: If you need more space, you can write at the back of this Form.
(*Tala: Kung kailangan mo ng karagdagang patlang, maaari mong isulat sa
likod ng Form na ito.)
FORM 1-SCC
FOR OFFICIAL USE ONLY
(Para sa Opisyal na gamit lamang)
To be accomplished by the Branch Clerk of Court

(Sasagutan ng Kawani ng Hukuman)

Page (pahina) 4

2. Plaintiff claims the

defendants
owes 55,819.00 as June 30,
2011 .
(Ang Hinahabla ay umutang
sa
Naghahabla ng halagang
(55,819.00)
(a) Why does the defendant
owe
plaintiff money?
(Bakit ang Hinahabla ay
nagkautang ng salapi sa
Naghahabla?)
Defendants Dungog and Areo
obtained a loan from defendant
Floro. Floro, holding himself
solidarily liable, then assigned the
credit to IFC. Thus, IFC is now the
creditor and can collect the loan.
(If you need more space, please use
the back page). (Kung kailangan mo
ng karagdagang patlang, maaaring
gamitin ang likod ng pahinang ito.)

1. Cause of action
____ Check
__/_ Promissory Note
____ Contract
___ Oral
__/__ Written
_____ Barangay Agreement
_____ Injuries :
___ Accidental ___
Intentional
______ Damage to Property
______ Other (Please specify):
_____________________________________)
2. ____ Barangay conciliation required.
If yes, _____ Certificate to File
Action
_____ Compromise
Agreement
attached.
___/___ Barangay conciliation not
required.
Please state the reason) IFC is
a corporation.

(b) When did this happen?

(Kailan ito nangyari?)
Date: October 2005
(Petsa)
If no specific date, give the time period:
(Kung walang tiyak na petsa, ibigay ang tantiyang panahon)
Date started:______________
(Petsa nagsimula)
Through: ______________

(Hanggang)
(c) How did you compute the money owed to you? (Do not include
court
costs or fees)
A penalty charge of 3% per month is imposed compounded every time
defendants failed to pay the monthly instalment. Payments made by
defendants are applied first on the penalty charge and if fully settled the
excess if any is applied to principal.
(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?)
[/] Yes
(Oo)

[] No
(Hindi

FORM 1-SCC
Page (pahina) 5

If no, explain: ________________________________________________

(Kung hindi, ipaliwanag)
(b) How did you ask the defendant?
(Paano mo siningil ang Hinahabla?)

[]

In person
(Sa kanya mismo)

[/]

In writing
_______________
(Sa sulat)

[/]By phone
(Sa telepono)

[]Others (please specify)

(Iba pa) [pakisulat kung paano]

(c) When did you do this? March 2011

(Kailan mo ginawa ito?)
4. What is your proof that defendant owes you money? promissory note,
deed of assignment, chattel mortgage, ledger.
(Ano ang iyong katibayan o pruweba na ang Hinahabla ay may utang
na salapi sa iyo?)
5. Did you attach your proof to this form?
(Iyo bang inilakip ang katibayan o pruweba sa Form na ito?)

[/]

[]

Yes

(Oo)

(Hindi)

6. Was this claim referred to the barangay?

(Dumaan ba sa barangay ang paniningil na ito?)

[]

[]No

Yes

Covered
(Oo)

No

[/]

Not

(Hindi)

(Hindi sakop)
State reason:
(Isulat ang dahilan)
IFC is a juridical
entity
If yes, do you have a Certificate to File Action or a Compromise
Agreement executed before the barangay? N/A
(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 cases have
you filed within this calendar year prior to this present case?
This is the first
(Sa court station na ito, pang ilang kaso na itong isinampa mo
sa loob ng kasalukuyang taon? ______)
FORM 1-SCC
Page (pahina) 6

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.)

PRAYER
(PAGSAMO)

WHEREFORE, plaintiff respectfully prays for judgment ordering

defendant to pay the amount of 55,819.00, with 3% penalty charge and
legal interest per annum/per month from filing of this case until fully
paid.
(DAHIL DITO, ang Naghahabla ay magalang na sumasamo na
igawad ang kapasiyahang utusan ang Hinahabla na magbayad sa
Naghahabla ng halagang 55,819.00 pati ang 3% penalty charge at
tubo na bawat taon/buwan simula sa paghabla hanggang ganap o
lubos na mabayaran ito.)
Iloilo City, Philippines, _______________, 20___.
PLACE WHERE FILED
(Lugar kung saan inihain)
Iloilo Finance Corporation
PLAINTIFF
(Naghahabla)
.
by:
Arlene L. Locsin
CTC No. ___________
Issued at Iloilo City
Issued on __________

VERIFICATION
and
CERTIFICATION OF NON-FORUM SHOPPING
I, ARLENE L. LOCSIN, under oath depose and say:
That I am the authorized representative of Iloilo Finance Corporation.
That I have caused the preparation of the foregoing complaint, have read and
understood the contents thereof and all the allegations contained therein are true and
correct of my own personal knowledge and based on authentic record.

That Iloilo Finance Corporation has not commenced any other action or
proceedings involving the same or similar issues in the Supreme Court, the Court of
Appeals, or different divisions thereof, or in any other tribunal and agency; and that no
such action or proceeding is pending in the Supreme Court, Court of Appeals, or any
divisions thereof or any other tribunal and agency; and
That if I should thereafter learn that a similar action or proceeding has been filed
or is pending before the Supreme Court, the Court of Appeals or any other tribunal or
agency, I undertake to report such fact within five (5) days therefrom to the Court or
agency wherein the original complaint has been filed.
IN WITNESS WHEREOF, I hereunto
_____________________ at Iloilo City, Philippines.

affixed

my

signature

this

ARLENE L. LOCSIN
Affiant
C.T.C. No. 09790401
Issued at Iloilo City
Issued on February 3, 2011
REPUBLIC OF THE PHILIPPINES )
CITY OF ILOILO
)S.S.

JURAT/NOTARIAL CERTIFICATE
The principal, whose name and personal circumstances are stated above, appeared in
person before me this _______________________ in the City of Iloilo, presented the foregoing
instrument, signed the same in my presence, and affirmed or swore under oath to the truth and
correctness of the contents and allegations of the same.
IN WITNESS WHEREOF, I have hereunto set my hand and affixed my notarial seal on
the date and place above-written.
Doc. No. _______
Page No. _______
Book No. _______
Series of 2011.