FORM 1-A-BP22-SCC

VERIFICATION AND CERTIFICATION OF NON-FORUM SHOPPING

Jose T. Cuervo
I, __________________________________, Filipino
of legal age, ___________________
(name) (citizenship)
single
_______________________, and a resident of __________________________________
11th Avenue cor MH Del Pilar St.,
(civil status) Brgy
90 Zone 8 District 2, Caloocan City
_______________________________________________________________________,
on oath, state:

plaintiff
1. That I as the __________________ in the above-entitled case have caused this
foregoing statement of claim
_______________________________________________ to be prepared; that
I read and understood its contents which are true and correct of my own
personal knowledge and/or based on true records;

2. That I have not commenced any action or proceeding involving the same issue
and specifically the same check/s in the Supreme Court, the Court of Appeals
or any other tribunal or agency, particularly before the Office of the City
Caloocan
Prosecutor of ____________________________________; that to the best of
my knowledge, no such action or proceeding is pending in the Supreme Court,
the Court of Appeals or any other tribunal or agency, and that, if I should
learn thereafter that a similar action or proceeding has been filed or is pending
before these courts or tribunal or agency, I undertake to report that fact to the
Court within five (5) days therefrom.

3. That I knowingly and voluntarily waive and forego the institution of any
criminal complaint for Violation of Batas Pambansa Blg. 22 against the
defendant herein based on the same check/s subject matter of this Small
Claims Complaint.

21st
IN WITNESS WHEREOF, I have hereunto set my hand this ___________ day of
April
_____________________, 21
20_____.

Jose T. Cuervo
_____________________________
Affiant

21st
SUBSCRIBED AND SWORN to before me this _________day April
of ______________,
20____.
21

NOTARY PUBLIC