VERIFICATION AND CERTIFICATE OF NON-FORUM SHOPPING

I, Juan Dela Cruz, of legal age, single, Filipino and a resident of ADDRESS, after being duly sworn in
accordance with law, depose and say:

1. That I am the plaintiff in the above-entitled case for CASE NAME;

2. That I have caused the preparation and filing of the foregoing complaint;

3. That I have read and understood the contents thereof, and the same are true and correct to the best of
my personal knowledge and based on authentic documents;

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

5. That to the best of my knowledge, no such action or proceeding is pending in the Supreme Court, the
Court of Appeals, or the different divisions thereof, or any other tribunal or agency;

6. That if I should hereafter learn that a similar action or proceeding has been filed or pending in the
Supreme Court, the Court of Appeals, or the different divisions thereof, or any other tribunal or agency, I
hereby undertake to inform this Honorable Court of such fact within five (5) days from such notice.

IN WITNESS WHEREOF, I have hereunto set my signature this __ day of Month, 2012 at Tacloban City,
Philippines.
Signature of Affiant
Juan Dela Cruz
Affiant

SUBSCRIBED AND SWORN to before me this __day of Month, 2012 at Tacloban City, Philippines.

ATTY. JOSE D. HUSTISYA

Doc. No. 1 2 3 Notary Public
Page No. 4 5 6 Until December 31, 2012
Book No. XXX PTR No. 1234567
Series of 2012 January 01, 2011 / Tacloban City
Roll No. 12345 / TIN 123-456-789
________________________________________________________________________________

Signature for Counsel

ATTY. JOSE D. HUSTISYA
Counsel for Plaintiff/Defendant
Brgy. Apitong, Tacloban City
PTR No. 1234567*01/01/11*Tacloban City
IBP OR No. 123456*01/01/11*Tacloban City
Roll No. 12345/TIN 123-456-789
MCLE Compliance No. XXX-0001234
January 01, 2012