VERIFICATION AND CERTIFICATE OF NON-FORUM SHOPPING I, Juan Dela Cruz, of legal age, single, Filipino and a resident of ADDRESS,

after being duly sworn in accordance with law, depose and say: 1. That I am the plaintiff in the above-entitled case for CASE NAME; 2. That I have caused the preparation and filing of the foregoing complaint; 3. That I have read and understood the contents thereof, and the same are true and correct to the best of my personal knowledge and based on authentic documents; 4. That I have not commenced any other action or proceeding involving the same issue in the Supreme Court, the Court of Appeals, or the different divisions thereof, or any other tribunal or agency; 5. That to the best of my knowledge, no such action or proceeding is pending in the Supreme Court, the Court of Appeals, or the different divisions thereof, or any other tribunal or agency; 6. That if I should hereafter learn that a similar action or proceeding has been filed or pending in the Supreme Court, the Court of Appeals, or the different divisions thereof, or any other tribunal or agency, I hereby undertake to inform this Honorable Court of such fact within five (5) days from such notice. IN WITNESS WHEREOF, I have hereunto set my signature this __ day of Month, 2012 at Tacloban City, Philippines. Signature of Affiant Juan Dela Cruz Affiant SUBSCRIBED AND SWORN to before me this __day of Month, 2012 at Tacloban City, Philippines. ATTY. JOSE D. HUSTISYA Doc. No. 1 2 3 Notary Public Page No. 4 5 6 Until December 31, 2012 Book No. XXX PTR No. 1234567 Series of 2012 January 01, 2011 / Tacloban City Roll No. 12345 / TIN 123-456-789 ________________________________________________________________________________ Signature for Counsel ATTY. JOSE D. HUSTISYA Counsel for Plaintiff/Defendant Brgy. Apitong, Tacloban City PTR No. 1234567*01/01/11*Tacloban City IBP OR No. 123456*01/01/11*Tacloban City Roll No. 12345/TIN 123-456-789 MCLE Compliance No. XXX-0001234 January 01, 2012