VERIFICATION AND CERTIFICATION

OF NON-FORUM SHOPPING

I, ________________, Filipino, of legal age, married and a

resident of _______________________ after having duly sworn to in
accordance with law, do hereby depose and state:

1. That I am the Petitioner in the above-entitled case;

2. That I have caused the preparation and filing of the

foregoing Petition and I have read all the allegations therein
which are true and correct based on my personal knowledge
and authentic documents;

3. That I further certify that there is no pending action or

proceeding involving the same issues in the Supreme Court,
Court of Appeals, or any other tribunal or agency. If I
should thereafter learn that the same or similar action is
pending, I shall undertake to inform the Honorable Court of
this fact within five (5) days therefrom.

IN WITNESS WHEREOF, I have hereunto affixed my signature

this ____ day of ___________ in __________________.

______________________________
Affiant

SUBSCRIBED AND SWORN TO before me this ___day of

________, 20___ in _________with Driver’s License No. _________,
valid until __________ and I hereby certify that I personally
examined the affiant herein and that I am fully satisfied that she
voluntarily executed the foregoing petition and she understood all the
allegations herein.

Page No. ; Notary Public

Doc. No. ;
Book No. ;
Series of 2011.