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Republic of the Philipppines )

Province of Iloilo ) S.S.


City of Iloilo
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VERIFICATION AND CERTIFICATION

I, Ma. Lorna O Beriones, of legal age, Filipino, single, and a resident of 1100 5th Main
Avenue, Alta Tierra Village, Jaro, Iloilo City, after having been duly sworn in accordance with
law, depose and state that:

1. I am a plaintiff in the above-stated case;

2. I caused the preparation of the foregoing complaint;

3. I have read the contents thereof and the facts stated therein are true and correct
of my personal knowledge and/or on the basis of copies of documents and
records in my possession;

4. I have not commenced any other action or proceeding involving the same issues
in the Supreme Court, the Court of Appeals, or any other tribunal or agency;

5. To the best of my knowledge and belief, no such action or proceeding is pending


in the Supreme Court, the Court of Appeals, or any other tribunal or agency;

6. If I should thereafter learn that a similar action or proceeding has been filed or is
pending before the Supreme Court, the Court of Appeals, or any other tribunal or
agency, I undertake to report that fact within five (5) days therefrom to this
Honorable Court.

IN WITNESS WHEREOF, I have hereunto set my hand this 24th day of April, 2017.

Ma. Lorna O Beriones


Affiant

SUBSCRIBED AND SWORN to before me, this 20th day of April 2017 in Iloilo City, with
affiant exhibiting her TIN Card ID with ID No.: 000-123-456-789 issued by the Bureau of
Internal Revenue, Iloilo City on June 1, 2009.

Atty. Juan Dela Cruz


NOTARY PUBLIC
PTR No. 1234567, Iloilo City, 1/2/17
IBP OR No. 654321, Iloilo City, 1/2/17
Attorneys Roll No. 11223
MCLE Compliance Certificate No. IV-0012345, Iloilo City, 1/2/17

Doc. No. : ________;


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Book No. : ________;
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