VERIFICATION AND CERTIFICATION

REPUBLIC OF THE PHILIPPINES)

Province of____________________) S.S.

City/Municipality of_____________)

            I, _________________, of legal age, Filipino, (single / married / widow), and a resident of _______________, 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 quasi-judicial 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 there from 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 hands this _____________, at ______________, Philippines.

                                                                       AFFIANT

            SUBSCRIBED AND SWORN to before me, this _____________, by _____________ who exhibited to me (his/her) Community Tax Certificate No. _____________ issued at _____________, Philippines on ____________.

                                                                                    NOTARY PUBLIC

Doc. No.________;

Page No.________;

Book No.________;

Series No________;

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