Republic of the Philippines

Department of Labor and Employment

NATIONAL LABOR RELATIONS COMMISSION
Regional Arbitration Branch No. VI
Bacolod City
-oOo-
____________________________________
____________________________________
Complainant/s,

-versus- NLRC, RAB Case No. VI- ____________

____________________________________
____________________________________
____________________________________
Respondent/s.

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

COMPLAINT
Complainant/s, by counsel, respectfully state as follows:

1. Name of Complainant/s: ____________________________ SEX: ___ AGE: ___ STATUS: ______

No. of Complainant/s: (M) _____ (F):______
2. Address: _______________________________________________________________________
3. Name of Respondents: ___________________________________________________________
4. Address: _______________________________________________________________________
5. Position: ( )Owner ( ) Manager ( ) President / Vice President ( ) _______________________
6. ADDRESS: ______________________________________________________________________
7. Nature of Business: ____________________ Number of Workers: ________________________
8. Date Employed: _______________________ Date Dismissed:____________________________
9. Nature of Work/Position: ________________ Schedule of Work: _________________________
10. Place of Work: __________________________________________________________________
11. Salary Rate: __________________________ Frequency of Payment: ______________________
12. Are you a union member? ( ) Yes ( ) No
Name of Union: __________________________________________________________________
Is there an existing CBA? ( ) Yes ( ) No
13. Have you filed any similar case? ( ) Yes ( ) No
If yes, where? _____________________________________________________________________

CAUSE OF ACTION

Underpayment of: Non-payment of:

A. Unfair Labor Practice ( ) 6. Retirement pay ( ) ( )

Specify: ____________________ 7. Holiday Pay ( ) ( )
B. Illegal Suspension ( ) 8. Service Incentive leave ( ) ( )
Pay
C. Illegal Dismissal ( ) 9. Vacation/Sick Leave ( ) ( )
Actual ( ) 10. 13th Month Pay ( ) ( )
Constructive ( ) H. Damages
D. Illegal Lay-off/retrenchment ( ) 1. Moral & Exemplary ( )
E. Regularization ( ) 2. Actual ( )
F. Illegal Deductions ( )
Specify: ___________________
G. Underpayment of: Non - payment of:
1. Salaries/Wages ( ) ( ) I. Others: _________________ ( )
2. Overtime Pay ( ) ( ) Specify: ________________ ( )
3. Premium Pay ( ) ( ) _________________ ( )
For Holiday _________________ ( )
4. Allowance ( ) ( ) _________________ ( )
5. Separation Pay ( ) ( ) ATTORNEYS FEES: _________ ( )
 RELIEF

Complainant prays for the following:

Separation Pay, in the event when reinstatement to his former position is no longer deemed
feasible, and payment of the above-stated monetary benefits.

Other relief and remedies, just and equitable under the premises, are likewise most respectfully prayed
for.

Bacolod City this _________________ .

__________________________

Complainant/s

__________________________

Counsel for the Complainants

 Garcilliano and Garcilliano Law Offices
(BS Aquino Drive, Bacolod, Negros Occidental, Philippines)
Tel. No. (034) 567112

by:

ATTY. Louem G. Garceniego

Roll of Attorneys No. ___ ____
MCLE COC __________________
PTR No. ____________________; Bacolod City
IBP OR No. ____________________; Negros Occidental Chapter
 VERIFICATION WITH CERTIFICATION OF NON-FORUM SHOPPING

I, ____________________, of legal age, married, a Filipino citizen and a resident of Bacolod

City, being duly sworn to, in accordance with law, hereby deposes and states that:
1. I am the Complainant in the above-entitled case and have caused the foregoing Complaint to
be prepared and filed;
2. I have read and understood its contents which are true and correct of my own personal
knowledge and/or based on authentic records;
3. I have not commenced any action or proceeding involving the same issue with the Supreme
Court, the Court of Appeals or any other tribunal or agency; that to the best of my knowledge,
no such action or proceeding is pending in the Supreme Court, the Court of Appeals or any
other tribunal or agency, and that, if we should learn thereafter that a similar action or
proceeding has been filed or is pending before any of the said courts, tribunal or agency, I
undertake to report that fact to the Honorable Office within five (5) days from notice
therefrom.
IN TRUTH AND WITNESS WHEREOF, I hereunto set my hand this 16 November 2017 in Bacolod
City, Philippines.

___________________
Affiant
Govt issued I.D. No.: ___________

SUBSCRIBED AND SWORN TO BEFORE ME, for and in the City of Bacolod, this ___________,
Affiant who is personally known to me and to me known to be the same person, personally
appeared to me and signed the foregoing as noted above.

Witness my hand and seal.

Doc. No. ______;

Page No. ______;
Book No. ______;
Series of 2017.