Republic of the Philippines }

Cagayan de Oro City } S.S.

x-------------------------------------/

VERIFICATION AND CERTIFICATION

AGAINST NON-FORUM SHOPPING

I, ____ of legal age, Filipino, widowed, and a resident of Purok 3,

Barangay Extension, Wao, Lanao del Sur, under oath state that:

1. I am the plaintiff in the above captioned case;

2. I have caused the preparation of the above Complaint;
3. I have read and understood the material allegations therein and
the same are true and correct of my own and personal knowledge and belief;
4. I further testify that: (a) I have not theretofore commenced any
other action or proceeding or filed any claim involving the same issues or
matter in any court, tribunal, or quasi-judicial agency, and (b) to the best of my
knowledge, no such action or proceeding is pending therein; (c) if I should
thereafter learn that the same or similar action or proceeding has been filed or
is pending before the Supreme Court, the Court of Appeals, or any other
tribunal or quasi-judicial agency, I undertake to report such fact within five (5)
days therefrom to the court or agency wherein the original pleading and sworn
certification contemplated herein has been filed.

IN WITNESS WHEREOF, I affix my signature this

________________ in the City of Cagayan de Oro, Philippines.

Affiant
I.D. Presented: Senior Citizen ID
I.D. Number: 2729
Issued at Wao, Lanao del Sur

SUBSCRIBED AND SWORN to before me this _________________,

at Cagayan de Oro City, Philippines by the above named affiant who presented
to me his abovementioned identification card bearing his photograph and
signature thereon.

Doc No. ______

Page No. _____
Book No. _____
Series of 2018.