VERIFICATION AND CERTIFICATION OF NON-FORUM SHOPPING (OF

PLEADING)

VERIFICATION AND CERTIFICATION

REPUBLIC OF THE PHILIPPINES )

CITY OF ____________________ ) S.S.

I, ____________________, Filipino, of legal age residing at ____________________, after

being sworn to 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)

Signature of Affiant

JURAT