VERIFICATION AND CERTIFICATION OF NON-FORUM SHOPPING I, ________________, Filipino, of legal age, married and a resident of _______________________ after

having duly sworn to in accordance with law, do hereby depose and state: 1. That I am the Petitioner in the above-entitled case; 2. That I have caused the preparation and filing of the foregoing Petition and I have read all the allegations therein which are true and correct based on my personal knowledge and authentic documents; 3. That I further certify that there is no pending action or proceeding involving the same issues in the Supreme Court, Court of Appeals, or any other tribunal or agency. If I should thereafter learn that the same or similar action is pending, I shall undertake to inform the Honorable Court of this fact within five (5) days therefrom. IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of ___________ in __________________.

______________________________ Affiant SUBSCRIBED AND SWORN TO before me this ___day of ________, 20___ in _________with Driver’s License No. _________, valid until __________ and I hereby certify that I personally examined the affiant herein and that I am fully satisfied that she voluntarily executed the foregoing petition and she understood all the allegations herein.

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

Notary Public

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