VERIFICATION/CERTIFICATION OF FORUM SHOPPING

Republic of the Philippines )

City of Manila
) S.S.

I, MARIA, of legal age, Filipino citizen, MARRIED and resident of 123 SITIO MALIGAYA,
ANGELES CITY, after having been duly sworn to in accordance with law do hereby depose and say:
1.

That I am the plaintiff in the above-entitled case;

2.

That I have caused the preparation of the foregoing complaint and have read the allegations
contained therein;

3.

The allegations in the said complaint are true and correct of my own knowledge and
authentic records;

4.

I hereby certify that I have not commenced any other action or proceeding 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 therein;

5.

That if I should learn thereafter that a similar action or proceeding has been filed or is
pending, I hereby undertake to report that fact within five (5) days therefrom to the court or agency
where the original pleading and sworn certification contemplated herein have been filed;

6.

I executed this verification/certification to attest to the truth of the foregoing facts and to
comply with the provisions of Adm. Circular No. 04-94 of the Honorable Supreme Court.
IN WITNESS WHEREOF, I have hereunto affixed my signature this November 2016, in the
City of ANGELES.

MARIA

SUBSCRIBED AND SWORN to before me this November, 2016, in the City of ANGELES,
affiant exhibiting to me his Drivers License No. 12345 issued by the Land Transportation Office on
November 2016 at the City of ANGELES.

ATTY. NO CASE
Notary Public
My Commission Expires Dec. 31, 2012
Roll of Attorney No. 34567
IBP No. 12345/2-5-12/PAMPANGA
PTR No. 87654/12-22-11/PAMPANGA

Doc. No. ________

Page No. _______
Book No. _______
Series of 2012.