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Republic of the Philippines

Third Judicial Region


Municipal Trial Court
Sta. Maria, Bulacan

PERSEVIRANDA CRUZ
MENDOZA, doing business
in the name and style of
CMCM FEEDS SUPPLY &
VETERINARY CENTER,
Plaintif,

-versus- SMALL CLAIMS CASE


NO.______
For: Collection of Sum of
Money

MR. EFREN GO, joined by


his wife, JANE DOE,
Defendants.
x---------------------
-x

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

CMCM FEEDS SUPPLY & VETERINARY CENTERS


NAME OF PLAINTIFF/S

(Put check on the following)

INDIVIDUAL CORPORATION PARTNERSHIP

COOPERATIVE SOLE
PROPRIETORSHIP

HOME ADDRESS: J.P. Rizal St., Poblacion, Sta. Maria, Bulacan


3022 ;

Zip Code
(Province, if applicable) Bulacan
3022 ;
Zip Code

Telephone No. N/A Cellphone No. 0915-394-6032


PLACE OF WORK: SAME

NAME OF REPRESENTATIVE: PERSEVIRANDA C. MENDOZA


HOME ADDRESS: (City) 67 Caypombo, Sta. Maria,
3013
Zip Code
( Province, if applicable) Bulacan
3013
Zip
Code

Telephone No. N/A Cellphone No.0939-930-9800

MR. EFREN GO Male unknown


married ;
NAME OF DEFENDANT/S SEX AGE CIVIL
STATUS

(Put check on the following)

INDIVIDUAL CORPORATION PARTNERSHIP

COOPERATIVE SOLE
PROPRIETORSHIP

HOME ADDRESS: (City) No. 0320 Brgy. Gaya-Gaya, San Jose Del Monte
3023

Zip Code
(Province, if applicable) Bulacan
3023 ;
Zip Code

Telephone No. N/A Cellphone No. N/A

PLACE OF WORK: N/A

NAME OF REPRESENTATIVE, if applicable N/A

HOME ADDRESS: (City) N/A N/A


Zip Code
( Province, if applicable) N/A
N/A
Zip Code

Telephone No. N/A Cellphone No. N/A


PLACE OF WORK: N/A

Telephone No. N/A Cellphone No. N/A

FOR OFFICIAL USE ONLY


To be accomplished by the Branch Clerk of
Court
2. Plaintiff claims the defendant owes
Eighty Five Thousand Two Hundred 1. Cause of action
Fifty Pesos (P85,250.00) Check
Promissory Note
(a) Why does the defendant owe Contract
Plaintiff money? Oral Written

The defendant received agricultural Barangay Agreement


and veterinary products Injuries
Accidental Intentional
(If you need more space, please use Damage to Property
Back page), Other (Please specify):
___________________________)
(a) When did this happen? 2. Barangay conciliation required.
Date: April 8, 2011 If yes, __ Certificate to File Action
April 12, 2011 __Compromise Agreement attached
May 12, 2011
May 21, 2011 Barangay conciliation not required.
Please state the reason)
_____________________________________

If no specific date, give the time


Period:
Date started:
Through:

(c) How did you compute the money owed to you? (Do not
include court costs or fees) The Sales Invoice issued by the
Plaintiff, signed by the Defendant.

3. (a) Did you ask the defendant to pay you before you
filed this case?

Yes No

If no, explain:___________________________________________________________

(b) How did you ask the defendant?


In person By phone

In writing Others (please specify)

(c) When did you do this? 18 January 201610 October 2014

4. What is your proof that defendant owes you money? The Sales
Invoice issued by the Plaintiff, signed by the Defendant.

5. Did you attach your proof to this form?

Yes No

6. Was this claim referred to the barangay?

Yes No Not Covered

State reason:
The parties live in
different municipalities

If yes, do you have a Certificate to File Action or a Compromise


Agreement Executed before the Barangay? N/A

6-A- In this court station, how many small claims cases have
you filed within this calendar year prior to this present case? 3

7. BY THE FILING OF THIS ACTION, PLAINTIFF HEREBY WAIVES ANY


AMOUNT IN EXCESS OF P200, 000.00, EXCLUDING INTEREST AND
COSTS.

PRAYER

WHEREFORE, plaintiff respectfully prays for judgment ordering


defendant to pay the amount of EIGHTY FIVE THOUSAND TWO
HUNDRED FIFTY PESOS (P85,250.00) with interest at the rate
24% per annum, from 18 January 2016 until fully paid.

Sta. Maria, Bulacan, ___ September 2016.

PERSEVIRANDA C. MENDOZA
PLAINTIFF
REPUBLIC OF THE PHILIPPINES }
City of Meycauayan } S.S.

AFFIDAVIT

I, PERSEVIRANDA C. MENDOZA, Filipino, of legal age, and with


residence at 67 Caypombo, Sta. Maria, Bulacan, on oath, hereby depose
and state that:

1. I am the Sole Proprietor of CMCM Feeds Supply & Veterinary


Center with office address at New Public Market, J.P. Rizal St., Poblacion, Sta.
Maria, Bulacan.

2. I caused the preparation and institution of a Small Claims case


against Mr. Efren Go (Efren) joined by his wife, Jane Doe, entitled
Perseviranda Cruz Mendoza, doing business in the name and style
of CMCM Feeds Supply & Veterinary Center v. Mr. Efren Go, joined
by his wife, Jane Doe, to be filed before the Municipal Trial Court of Sta.
Maria, Sta. Maria, Bulacan;

3. Based on existing records and my direct personal knowledge of


the factual circumstances relevant to this case, from April 8, 2011 to May
21, 2011, Efren received agricultural and veterinary products from CMCM
amounting to EIGHTY FIVE THOUSAND TWO HUNDRED FIFTY PESOS
(P85,250.00) which remains to be unpaid as of the filing hereof;

4. Oral and written demands notwithstanding, Efren still refuses to


settle his arrears to me.

5. I am executing this Affidavit pursuant to Sec. 9 of the 2016


Revised Rules of Procedure for Small Claims Cases.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___


day of September 2016, here at the City of Meycauayan, Bulacan.

PERSEVIRANDA CRUZ MENDOZA


Affiant

SUBSCRIBED AND SWORN TO before me this ___ day of September


2016 here at the City of Meycauayan, Bulacan. As proof of identity, affiant
exhibited to me her _________________________.

Doc. No. ____;


Page No. ____;
Book No. ____;
Series of 2016.