VERIFICATION/CERTIFICATION

OF NON-FORUM SHOPPING

I, _______________, of legal age, Filipino, married and a resident of

__________________________, after having been duly sworn to in accordance with
law, hereby depose and say:

That I am the complainant in the above entitled case; That I have caused the
preparation of the foregoing; That I have read the said complaint and the allegations
state therein are true and correct to my personal knowledge and/or based on authentic
records; That I further certify that I have not instituted a similar action with any other
courts or tribunal concerning the same cause or subject matter; To the best of my
knowledge, no such similar action or proceeding is pending or has been terminated; If
I should learn that a similar action or proceeding has been filed or is pending before the
Supreme Court, the Court of Appeals or any tribunal or agency, I undertake to report
the fact within five (5) days from knowledge hereof.

________________
Affiant
Republic of the Philippines)
Province of Bulacan. . . . .)s.s
City of Malolos. . . . . . . . )

SUBSCRIBED AND SWORN to before me this __________ hereat

__________________. Affiant exhibiting to me his CTC NO. ____________ issued on
__________ at _______________.