REPUBLIC OF THE PHILIPPINES )

CITY OF ILIGAN ) S.S.

VERIFICATION AND CERTIFICATION

I, __________, Filipino, of legal age residing at with law,

deposes and says that:

1. I am the Plaintiff in the above-entitled case;

2. The facts stated in the above complaint are true and correct
to the best of my knowledge and authentic records;

3. I have not commenced any action or filed any claim

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 in them; and

4. If I should learn that the same or similar action or claim has

been filed or is pending after its filing, I shall report that fact
within five (5) days from notice to the court or where the
complaint or initiatory pleading has been filed.

(Date and venue)

Signature of Affiant

SUBSCRIBED and sworn to before me, this ___ day of ________, in

the City of __________ by _____________ with Passport No. ______,
Issued on _____________ at __________________.

Doc. No. _____;

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