(Verification with Certification of Non-Forum Shopping)

VERIFICATION AND CERTIFICATION

REPUBLIC OF THE PHILIPPINES)
Province of Surigao Del Norte
) S.S.
Surigao City
)
x-----------------------x
I, Juan dela Cruz, of legal age, Filipino, single and a resident of Borromeo Street,
Barangay Taft, Surigao City, Surigao del Norte, Philippines, after being sworn in accordance
with law, hereby depose and say:
That I am the (Plaintiff / Complainant / Petitioner) in the above-entitled case; That I have
caused the preparation of the above (Complaint / Petition) and I have read the same and knows
the contents thereof; That the allegations contained therein are true and correct of my own
personal knowledge.
That I further certify that: (a) I have not theretofore commenced any other action or
proceeding or filed any claim involving the same issues or matter in any court, tribunal, or quasijudicial agency and, to the best of my knowledge, no such action or proceeding is pending therein;
(c) if I should thereafter learn that the same or similar action or proceeding has been filed or is
pending before the Supreme Court, the Court of Appeals, or any other tribunal or quasi-judicial
agency, I undertake to report such fact within five (5) days therefrom to the court or agency wherein
the original pleading and sworn certification contemplated herein have been filed.
IN WITNESS WHEREOF, I have hereunto set my hand this 14th day of November at
Surigao City, Philippines.

AFFIANT
SUBSCRIBED AND SWORN to before me, this 14th day of November, by Juan dela
Cruz, who exhibited to me his Passport No. 12345H issued at Surigao City, Philippines on
August 25, 2012.

ATTY. HONEY JOY R. MILLANO

NOTARY PUBLIC FOR SURIGAO CITY
UNTIL DECEMBER 31, 2012
ROLL NO. 97865

PTR
NO. 001, DEC. 31, 2011, SC
IBP
NO. 002, DEC 31, 2011, SC
MCLE COMPLIANCE NO. 1234

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