CERTIFICATION REGARDING LITIGATION,

PROCEEDINGS AND INVESTIGATIONS

I, _______________________________________________, of legal age, Filipino, and
with address at _________________________________________________________________,
after being sworn in accordance with law, hereby state:
1.

I am applying with Uber Systems, Inc. ("USI") for the following: [Check the applicable
box]

2.

Accreditation as Transportation Network Vehicle Service (TNVS)

Accreditation as TNVS driver
Accreditation of TNVS vehicle
Issuance of Certificate of "Good Standing" as TNVS

Upon request of USI, I hereby certify as follows: [Check the applicable box. If you
choose the lower box, please provide the required information at the end of this form.]
I have not been a party to any litigation or other proceedings, or the subject of any
investigations (with or without a complaint being laid), whether completed or
pending, whether civil, criminal, administrative or otherwise, before any court,
tribunal, office, police, other law enforcement officer, or quasi-judicial agency in the
Philippines.
I am/have been a party to the litigation/other proceedings or am/was the subject of the
investigations described at the end of this form. [Describe the litigation/other
proceedings/investigations in the space provided at the end of this form]

3.

I hereby authorize USI, its Affiliates and/or related parties to: (a) verify the status of any
litigation/proceedings/investigations herein described; and (b) to disclose any information
I have provided, whether in this form or otherwise, whether provided before or after the
date hereof, or that they may gather in connection with their subsequent verification of
said information, to the LTFRB or other relevant court, agency, forum or other persons, as
may be necessary for purposes of processing my above application or in connection with
my being a TNVS, a driver of a TNVS or my TNVS vehicle.

4.

Further, I am executing this Certification, to attest to the truth of the foregoing facts,
voluntarily and with full knowledge and understanding that any false statement herein
may subject me to applicable criminal and/or administrative liabilities under existing
laws.
________________________________
Signature over printed name

DETAILS OF PENDING LITIGATION,

PROCEEDINGS AND/OR INVESTIGATIONS
[Describe the litigation/other proceedings/investigations
in the space below and in a separate sheet if necessary]

SUBSCRIBED AND SWORN to before me this ______ day of _______________________

2015, at _______________ City, affiant exhibiting to me the following:
Competent Evidence of Identity
Type of ID
Affiant

ID No. and
Expiry Date (if
applicable)

Community Tax Certificate

Number

Date and Place

Issued

2
I further certify that I have personally examined the affiant and that I am satisfied that he
understood and voluntarily executed this Certification.
NOTARY PUBLIC
Doc. No. ___;
Page No. ___;
Book No. ___;
Series of 2015.