REPUBLIC OF THE PHILIPPINES )

CITY OF __________________ ) SS.

x---------------------x

VERIFICATION AND CERTIFICATE OF NON-FORUM SHOPPING

I, , of legal age, Filipino and a resident of

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

1. I am the duly authorized representative/Atty-in-Fact of _______;

2. I have caused the preparation of the instant ___________________ to be filed with

the ________________________;

3. I have read and understood its contents and found them to be true and correct based
on my personal knowledge and authentic records.

4. The pleading is not filed to harass, cause unnecessary delay, or needlessly increase
the cost of litigation;

5. The factual allegations therein have evidentiary support after reasonable

opportunity for discovery;

6. I have not heretofore commenced any other action or proceeding involving the
same issues in the Supreme Court, the Court of Appeals or different divisions
thereof, Court of Tax Appeals or different divisions thereof, or any other court,
tribunal or agency and to the best of my knowledge, there is no such other action or
claim pending therein;

7. 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 different divisions
thereof, Court of Tax Appeals or different divisions thereof, or any other court,
tribunal or agency, I undertake to promptly inform this Honorable Office within
five (5) calendar days therefrom.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ____ 20___ in
the City of _____________ , Philippines

Affiant

SUBSCRIBED AND SWORN TO before me this ______ day of _____ 20 ___ in the
City of _____________, Philippines, affiant exhibiting to me his/her____________ with ID No.
_____________ issued on _________________.

Doc. No. ______ ;

Page No. ______ ;
Book No. ______ ;
Series of 20__