VERIFICATION AND CERTIFICATION

REPUBLIC OF THE PHILIPPINES )

PROVINCE OF MASBATE )
MUNICIPALITY OF SAN JACINTO ) S.S

I, ____________, Filipino, of legal age residing at ___________________________,

after being sworn to be in accordance with law, deposes and says that:

1. I am the Plaintiff in the above-entitled case;

2. The facts stated in the above complaint are true and correct to the best of my knowledge
and authentic records;

3. I have not commenced any action or filed any claim involving the same issues in any
court, tribunal or quasi-judicial agency and, to the best of my knowledge, no such other
action or claim is pending in them; and

4. If I should learn that the same or similar action or claim has been filed or is pending after
its filing, I shall report that fact within five (5) days from notice to the court or where the
complaint or initiatory pleading has been filed.

(DATE and VENUE)

_____________________
AFFIANT

JURAT

SUBSCRIBED and sworn to before me, ____ day of ____, 2022 in the Municipality of
San Jacinto by _______ with (Identification details) _______ issued on ______ at ________ and
is valid until _______.

Doc. No. ____;

Page No. ____;
Book No. ___ ;
Series of 2022.