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VERIFICATION AND CERTIFICATION OF NON-FORUM SHOPPING

I, _______________________, of legal age, 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.

___________________________
Affiant

REPUBLIC OF THE PHILIPPINES)


CITY/MUNICIPALITY OF ______) SS.
ACKNOWLEDGMENT
BEFORE ME, a Notary Public for and in the (Province/ City/ Municipality) of ___________,
personally appeared _____________ with Community Tax Certificate No. ___________
issued on _____________ at _____________ (and Tax Identification No. (T.I.N.)
__________), and _____________ with Community Tax Certificate No. _____________
issued on _____________ at _____________ (and Tax Identification No. (T.I.N.)
_____________), both known to me and to me known to be the same persons who
executed the foregoing instrument which they acknowledged to me to be their free and
voluntary act and deed, consisting of only ______ (____) page/s, including this page in
which this Acknowledgement is written, duly signed by them and their instrumental
witnesses on each and every page hereof.

WITNESS MY HAND AND SEAL this _____________ at _____________, Philippines.


NOTARY PUBLIC

Doc. No. ______;


Page No. ______;
Book No. ______;
Series of ______;
PROSECUTORS CERTIFICATION

This is to certify that as shown by the records the undersigned, an authorized officer, that there is a
reasonable ground to believe that a crime has been committed and that the accused is probably guilty thereof;
that Rule 112 was complied with but address of the said accused could not be located.

Senior Assistant City Prosecutor

SUBSCRIBED AND SWORN to before me this 24th day of June 2015 in the City of Naga, Philippines.

City Prosecutor