FORM 1-A-BP22-SCC

VERIFICATION AND CERTIFICATION OF

NON-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

_________________, 20____ in _______________________.
Doc. No. ______;
Page No. _____;
Book No. _____;
Series of ______.

____

day

of