Republic of the Philippines…}

Province of Surigao del Sur…}

Tandag City…} S.S.

VERIFICATION
AND
CERTIFICATION OF NON-FORUM SHOPPING

I, ANNIE O. TY, Filipino, of legal age, and resident of Cabrera St. Bag-ong Lungsod,
Tandag City, Surigao del Sur, state under oath declare that:

1. I am the complainant in the above-captioned case;

2. I have caused the preparation of this Complaint;
3. I have read the contents herein and the same is true and correct based on authentic
records and personal knowledge;
4. I have not commenced a similar action for the same cause with any other court,
tribunal or quasi- judicial agency and, to the best of my knowledge, no such action or proceeding
is pending with any other court, tribunal or quasi- judicial agency; and if an action has been filed
or is pending in any court, tribunal or quasi- judicial agency, I hereby undertake to notify this
Honorable Court within five (5) days from such notice;

IN WITNESS WHEREOF, I have set my hand this _____________ in Tandag City,

Surigao del Sur.

ANNIE O. TY
Affiant
Driver’s License # L09-98-003418

SUBSCRIBED AND SWORN TO BEFORE ME, this _____________ in Tandag City,

Surigao del Sur, the affiant personally appeared and affixed her signature herein. I hereby certify
that the same is her free act and deed.