VERIFICATION AND CERTIFICATION OF NON-FORUM SHOPPING
I, __________________________________, of legal age, Filipino, married/single/widow/widower, and a resident of ______________________________________________________, on oath, state:
1. That I as the __________________ in the above-entitled case have caused this _______________________________________________ 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 and specifically the same check/s in the Supreme Court, the Court of Appeals or any other tribunal or agency, particularly before the Office of the City Prosecutor of ____________________________________; 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_____.
SUBSCRIBED AND SWORN to before me this _________day of ______________, 20____.