PREPUBLIC OF THE PHILIPPINES

MUNICIPAL TRIAL COURT 6TH Judicial Region Hinigaran, Negros Occidental -oOo-

RUSHCASH LENDING CORPORATION.,

( Hinigaran Branch) Plaintiff, -VersusBANA-AG, ELIZABETH C., BANA-AG, DANILO JR. E., and FLORES, ELIZA P., Defendant.P x---------------------------------------------------x SM CL No. Collection of Sum of money and Filing Fees

STATEMENT OF CLAIM (HABLA NG PAGSINGIL)

1. The personal circumstances of the parties are follows: (Ang bawat panig ay ang sumusunod) RUSHCASH LENDING CORPORATION NAME OF PLAINTIFF/S (Pangalan ng Naghahabla) (Put check on any of the following) (Pumili sa mga sumusunod at lagyan ng tsek) INDIVIDUAL (Tao/ Individual) COOPERATIVE (Kooperatiba) N/A SEX (Kasarian) N/A AGE (Edad) N/A CIVIL STATUS (Katayuang Sibil)

CORPORATION (Korporasyon)

PARTNERSHIP (Bakasan)

SOLE PROPRIETORSHIP (Solong Pagmamay-ari) 6106 Zip Code NONE 6106 Zip Code

HOME ADDRESS: (CITY) R.C Lagtapon St,, Hinigaran, Negros Occidental Pahatirang Sulat sa Bahay) [Lungsod] Telephone No. ( Telepono Blg.) 034-3917-499 Cellphone No: (Selfon Blg.)

PLACE OF WORK R.C Lagtapon St., Hinigaran, Negros Occidental (Lugar ng Pinagtatrabahuan) NAME OF REPRESENTATIVE, if applicable: (Pangalan ng Kinatawan, kung meron)

RESTITUTO P. CATACUTAN JR.

HOME ADDRESS: (CITY) c/o R .C Lagtapon St., Hinigaran, Negros Occidenatl __6106 (Pahatirang Sulat sa Bahay) [Lungsod] Zip Code

Telephone No. (Telepono Blg.)

NONE

Cellphone No: (Selpon Blg.) FEMALE SEX (Kasarian) N/A AGE (Edad)

09074808888 MARRIED CIVIL STATUS (Katayuang Sibil) PARTNERSHIP (Bakasan)

BANA-AG, ELIZABETH C. NAME OF DEFENDANT/S (Pangalan ng Hinahabla)

INDIVIDUAL (Tao/Indibidual)

CORPORATION (Korporasyon)

COOPERATIVE (Kooperatiba)

SOLE PROPRIETORSHIP (Solong Pagmamay-ari) 6106 Zip Code NONE

HOME ADDRESS: (City) Brgy.Gargato, kahilwayan, Hinigaran, Neg.Occ. (Pahatirang Sulat sa Bahay) [Lungsod] Telephone No. (Telepono Blg.) PLACE OF WORK (Lugar ng Pinagtatrabahuan) BANA-AG, DANILO JR.E. NAME OF DEFENDANT/S (Pangalan ng Hinahabla) NONE Cellphone No. (Selpon Blg.)

N/A MALE SEX (Kasarian) N/A AGE (Edad) MARRIED CIVIL STATUS (Katayuang sibil)

INDIVIDUAL (Tao/Indibidual)

CORPORATION (Korporasyon)

PARTNERSHIP (Bakasan)

COOPERATIVE (Kooperatiba)

SOLE PROPRIETORSHIP (Solong Pagmamay-ari) 6106 Zip Code NONE

HOME ADDRESS: (City) Brgy. Gargato, Kahilwayan, Hinigaran, Neg. Occ. (Pahatirang Sulat sa Bahay) [Lungsod] Telephone No. (Telepono Blg.) PLACE OF WORK (Lugar ng Pinagtatrabahuan) FLORES, ELIZA P. NAME OF DEFENDANT/S (Pangalan ng Hinahabla) NONE N/A FEMALE SEX (Kasarian) CORPORATION (Korporasyon) N/A AGE (Edad) Cellphone No. (Selpon Blg.)

MARRIED ____ CIVIL STATUS (Katayuang sibil) PARTNERSHIP (Bakasan)

INDIVIDUAL (Tao/Indibidual)

COOPERATIVE (Kooperatiba)

SOLE PROPRIETORSHIP (Solong Pagmamay-ari)

HOME ADDRESS: (City) Brgy. Gargato, Kahilwayan, Hinigaran, Neg. Occ. 6106 (Pahatirang Sulat sa Bahay) [Lungsod] Zip Code Telephone No. (Telepono Blg.) PLACE OF WORK (Lugar ng Pinagtatrabahuan) N/A NONE Cellphone No. (Selpon Blg.) NONE

2. Plaintiff claims the defendant owes Php. 3,757.09 (Ang hinahabla ay umutang sa naghahabla ng halagang )

1. Cause of action Check

Promissory Note
Contract Oral Written Barangay Agreement Injuries Accidental Damages to property Other: ) 2. No If yes, Barangay conciliation required Certificate to File Action Compromise Agreement attached. International

(a) Why does the defendant owe Plaintiff money? (Bakit ang hinahabla ay nagkautang ng salapi sa Naghahabla?) LOANED AMOUNT IN 4 MONTHS TERM (b) When did this happen? (Kailan ito nangyari?) Date: April 11, 2010 (Petsa)

If no specific date, give the time period: (Kung walang tiyak na petsa, ibigay ang tantiyang panahon) Date started: May 11, 2010 (Petsa nagsimula) Through: August 11, 2010 (Hangganga) ( c )How did you compute the money owed to you? Do not include court costs and fees. Php 3,757.09 with 8% interest per month and 25% collection charges as of May 06, 2011. (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)
N/A

NO (Hindi)

If no, explain: (Kung hindi, ipaliwanag)

(b) How did you ask the defendant? (Paano mo siningil ang Hinahabla?) In Person (Sa kanya mismo)

By phone (Sa telepono) Others (Iba pa) [pakisulat kung paano] May 06, 2011

In Writing (Sa sulat)

(c) When did you do this? (Kailan mo ginawa ito?)

4. What is your proof that defendant owes you a money? PROMISORRY NOTE AND DEMAND LETTER. (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)

NO (Hindi)

6. Was this claim referred to the barangay? (Dumaan ba sa barangay ang paniningil na ito?)

YES (Oo)

NO (Hindi)

Not Covered (Hindi sakop)

State reason: (Isulat ang dahilan) Not covered by the barangay under LGU Code

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 station, how many small claims cases have you filed within this calendar year prior to this present case? ____NONE_____________. (Sa court station na ito, pang ilang kaso na itong isinampa mo sa loob ng kasalukuyang taon? ______NONE__________). 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 P 100,000.00, hindi kasama ang tubo at gastos sa pagsampa ng kasong ito.)

PRAYER

WHEREFORE,

Plaintiff respectfully prays for judgment ordering the defendant to pay

the amount of (THREE THOUSAND SEVEN HUNDRED FIFTY-SEVEN PESOS AND 09/100) (Php. 3,757.09), with interest at the rate of 8% per month plus 25% collection charges as of May 06, 2011 until fully paid. That the plaintiff also respectfully prays that the filling fee totaling to the amount of (Php._________) be respectfully refunded by the defendant.

Hinigaran, Negros Occidental, Philippines._______________.

RUSHCASH LENDING CORPORATION

Represented By: RESTITUTO P. CATACUTAN JR.

REPUBLIC OF THE PHILIPPINES] HINIGARAN, NEGROS OCCIDENTAL SS. x--------------------------------------------x

VERIFICATION & CERTIFICATION OF NON-FORUM SHOPPING

I, RESTITUTO P. CATACUTAN JR. of legal age, Filipino, single and a resident of c/o R.C Lagtapon St., Hinigaran, Negros Occidental after having been duly sworn to, do hereby depose and state: That1. 2. 3. 4. I am the authorized representative of RUSHCASH LENDING CORPORATION, the Plaintiff in the above-entitled case; I have caused the preparation of this complaint; I have read and understood the statements therein and the same are true and correct to the best of my own knowledge and belief, and based on available authentic records; I hereby certify that I have not commenced any action or proceeding involving the same issues in any court, tribunal, or quasi-judicial agency and that to the best of my knowledge, no such action or proceeding is pending in any court, tribunal, or quasijudicial agency; If I should learn that a similar action or proceeding has been filed or is pending before any court, tribunal, or quasi-judicial agency, I will notify the court, tribunal or agency within five (5) days from such notice. FURTHER, AFFIANT SAYETH NAUGHT. Hinigaran, Negros Occidental, Philippines,

5.

RESTITUTO P. CATACUTAN JR. Affiant

SUBSCRIBED AND SWORN to before me this in the Municipality of Hinigaran, Negros Occidental, Philippines, affiant exhibited to me his SSS I.D No: 07-2294539- 1 as competent proof of his identity.

Doc. No. Page No. Book No. Series of 2011.

; ; ;

Notary Public

ATTACHED DOCUMENTS

Board Resolution Promissory Note Demand Letter

Annex A Annex B Annex C