Republic of the Philippines )

Tarlac City )

VERIFICATION AND CERTIFICATE

OF NON-FORUM SHOPPING

I, XXXXXXXXXXX, Filipino, of legal age, married and with residence at

XXXXXXXXXXXXXXX, after having been duly sworn in accordance with law do
hereby depose and state that:

1. I am the Complainant in the instant Complaint and have therefore caused its
preparation;

2. I have read the contents thereof and the facts stated therein as well as of the
annexes thereto;

3. I attest to the truth and correctness of the allegations therein and of the
annexes thereto to the best of my personal knowledge and/or on the basis of
copies of documents or records in my possession.

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

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

Supreme Court, the Court of Appeals or any tribunal or agency; and

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

XXXXXXXXXXXXXXXX
Affiant

SUBSCRIBED AND SWORN to before me this 6th day of June 2017 in

Tarlac City, affiant exhibiting to me his competent evidence of identity Senior Citizens ID
XXXXXXXXXX.