Republic of the Philippines}

City of ______________ } s. s.

VERIFICATION
AND CERTIFICATION OF NON-FORUM SHOPPING

I, _____________, Filipina, of legal age, married, and

a resident _______________________________________
after having been sworn in accordance with law hereby
depose and say that:

1. I caused the preparation of the foregoing pleading;

2. I have read the contents thereof hereby attest that the

allegations therein are true and correct of my personal
knowledge and/or based on authentic records;

3. To the best of my knowledge, there are no other pending

complaint of the same nature before any court, tribunal
or quasi-judicial agency; and

4. I undertake to promptly notify this Honorable Office

within five (5) days from actual knowledge of any similar
action or claim that may have been filed or is pending

IN WITNESS WHEREOF, I have set my signature this

_________ at _______________, Philippines.

______________________
Complainant

SUBSCRIBED AND SWORN TO before me this

_____________ at ____________, Philippines, affiant
exhibiting her ID bearing No. ______________, issued by
____________, and valid until ______.

WITNESS MY HAND AND SEAL.

Doc. No. _____; NOTARY PUBLIC

Page No._____;
Book No. _____;
Series of 2019.