Republic of the Philippines)

CITY OF DAVAO ) ss.

x---------------------------------x
VERIFICATION AND CERTIFICATION
ON NON-FORUM SHOPPING
I, POMILDA L DA!I"L, of legal age, married, Filipio, ad a re!ide" of Da#ao
Ci"$, P%ilippie!, af"er %a#ig &ee !'or "o i a((orda(e 'i"% la', do %ere&$ depo!e
ad !"a"e "%a")
*+ I am "%e Pe"i"ioer i "%i! i!"a" (a!e ad "%e #er$ !ame per!o i "%e a&o#e-
de!(ri&ed per!oal (ir(,m!"a(e!-
.+ I %a#e (a,!ed "%e prepara"io ad filig of "%e foregoig pe"i"io #ol,"aril$ ad
freel$-
/+ I %a#e read ad ,der!"ood "%e (o"e"! of "%e foregoig pe"i"io ad "%a" "%e
!ame are "r,e ad (orre(" "o m$ o' per!oal 0o'ledge ad &a!ed o
a,"%e"i( re(ord!-
1+ I %a#e o" (omme(ed a$ o"%er a("io or pro(eedig! i#ol#ig "%e !ame
i!!,e! i "%e S,preme Co,r", "%e Co,r" of Appeal!, or differe" di#i!io! "%ereof,
or a$ o"%er "ri&,al or age($, ad "o "%e &e!" of m$ 0o'ledge, iforma"io ad
&elief, o !,(% a("io or pro(eedig i! pedig i "%e S,preme Co,r", Co,r" of
Appeal!, or differe" di#i!io! "%ereof, or &efore a$ o"%er "ri&,al or age($+
S%o,ld I "%ereaf"er lear "%a" a !imilar a("io or pro(eedig %a! &ee filed or i!
pedig &efore "%e S,preme Co,r", "%e Co,r" of Appeal!, or a$ o"%er "ri&,al or
age($, I ,der"a0e "o repor" "%a" fa(" 'i"%i fi#e 234 da$! "%erefrom "o "%i!
Hoora&le Co,r"+
I! #IT!"$$ #%"R"OF, I %a#e %ere,"o !e" m$ %ad "%i! 555 da$ of 555555555
i Da#ao Ci"$, P%ilippie!+
ALLA! A. M"!DO&A
Affia"
SU6SCRI6ED ad !'or "o &efore me, i "%e Ci"$ of Da#ao, "%i! 555555 da$ of
555555555.7*/,
ATTY. AR!OLD V. DORIA
Do(+ No+ 5555 No"ar$ P,&li(
Page No+ 5555 U"il De(em&er /*, .7*/
6oo0 No+ 5555 PTR No+ */.88*9 7*:7.:.7*/
Serie! of .7*/ I6P No+ 991/73 *.:.7:.7*.
Roll No+ 3;/91
MC<E No+ III-77*=/7*
Da"e I!!,ed) *7:*7:.7*7