FORM 1-A-SCC

VERIFICATION AND CERTIFICATE OF

NON-FORUM SHOPPPING

I, _____________________________, of legal age,

(Name)
__________ ________ , and address
(citizenship) (civil status)

at ___________________________________,

after having been duly sworn to in accordance with law, hereby,

depose and say:
1. That I am the Complainant in the above-entitled case and
have caused this 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
authentic records.
2. That I have not commenced any action of proceeding
involving the same issue in the Supreme Court, the Court of
Appeals or any other tribunal or agency; that to the best of
my knowledge, no such action or proceeding is pending in
the Supreme Court, the Court of Appeals or any 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 of tribunal or agency, I undertake to report that
the fact to the Court within five (5) days therefrom.
IN WITNESS WHEREFOR, I have hereunto set my hand this
____ day of__________________,20____.

____________________
Affiant
SUBSCRIBED AND SWORN to before me this______day of
________, 20__.