VERIFICATION AND CERTIFICATION

OF NON-FORUM SHOPPING

I, _______________________, of legal age, Filipino and with office address at 21st Floor,
Lepanto Building, 8747 Paseo de Roxas, Makati City, under oath states that:

1) That I as the _________________ in the case entitled ______________________

docketed as _____________________ have caused this _______________________ 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 Prosecutor of
__________________________; that to the best of my knowledge, no such action or
proceeding has been 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 forgo 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.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of ____________,
20___.

_______________________
Affiant

SUBSCRIBED AND SWORN to before me this ___ day of __________________,

20___.

NOTARY PUBLIC