FORM 1-A-BP22-SCC

VERIFICATION AND CERTIFICATION OFNON-FORUM SHOPPING

I, , of legal age, Filipino, married and a resident of ________________________________________________, on oath state:

1. That I, as PLAINTIFF, in the above-entitled case have caused this STATEMENT OF CLAIM to be prepared; that I read and understood its contents which are true and correct of my own personal knowledge and/or based on true records.

2. That I have not commenced any action or proceeding involving the same issue in the Supreme Court, the Court of Appeals or any other tribunal or agency, particularly before the Office of the City Prosecutor; that to the best of my knowledge, no such action or proceeding is pending in the Supreme Court, the Court of Appeals or any other tribunal or agency, and that, if I should learn thereafter that a similar action or proceeding has been filed or is pending before these courts or tribunal or agency, I undertake to report that fact to the Court within five (5) days therefrom.

3. That I knowingly and voluntarily waive and forego the institution of any criminal complaint for violation of Batas Pambansa Blg. 22 against the defendant herein based on the same check/s subject matter of this Small Claims Complaint.

IN WITNESS WHEREOF, I have hereunto set my hand this ____ day of __________________, 20___ in ___________________________.

Affiant

SUBSCRIBED AND SWORN to before me this ____ day of _________________, 20____ in _______________________.

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