FORM 1-A-SCC

VERIFICATION AND CERTIFICATION AGAINST NON-FORUM SHOPPING, SPLITTING A SINGLE CAUSE OF ACTION AND MULTIPLICITY OF SUITS

I, __________________________________, of legal age, Filipino, married/single/widow/widower, and a resident of _________________________________________________, on oath, state:

1. That I am 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 or subject matter, 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 the filing of this case is not in violation of the rule against splitting a single cause of action or multiplicity of suits.

4. 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_____.

____________________________________________________

Affiant

SUBSCRIBED AND SWORN TO before me this _____ day of _________________.

NOTARY PUBLIC

Doc. No. _____

Page No. _____

Book No. _____

Series of 20___.