VERIFICATION AND CERTIFICATION OF NON-FORUM SHOPPING

I, Nelza Mae Humiwat-Madalang, of legal age, after having been duly

sworn in accordance with law, depose and state that:
1. I am the Petitioner in the above-stated case;
2. I caused the preparation of the foregoing complaint;
3. I have read the contents thereof and the facts stated therein are true and
correct of my personal knowledge and/or on the basis of copies of
documents and records in my possession;
4. I have not commenced any other action or proceeding involving the
same issues in the Supreme Court, the Court of Appeals, or any other
tribunal or agency;
5. To the best of my knowledge and belief, no such action or proceeding is
pending in the Supreme Court, the Court of Appeals, or any other tribunal
or agency;
6. If I should thereafter learn that a similar action or proceeding has been
filed or is pending before the Supreme Court, the Court of Appeals, or any
other tribunal or agency, I undertake to report that fact within five (5) days
therefrom to this Honorable Court.
IN WITNESS WHEREOF, I have hereunto set my hand this 10 th day
of April 2016 at San Fernando City.

Nelza Mae Humiwat-Madalang

Affiant
CTC No.: 02791178
Issued on: March 3, 2010
Issued at: San Fernando City, La Union
Passport ID No. 145268

Issued on: March 10, 2009

Valid Until: March 10, 2020

SUBSCRIBED AND SWORN to before me this 10 th day of April

2016 at San Fernando City, La Union affiant exhibiting to me his
Community Tax Certificate No. 02791178 issued on March 3, 2010 and
Passport ID bearing 145268 issued on March 10, 2009 and is valid until
March 10, 2020 in San Fernando City.

ATTY. Aiza B. Bencio

Counsel for the Petitioner
Roll No. 40885
B304, 3rd Floor, Kuala Building
San Fernando City, La Union
E-mail Address: imhotyournot@yahoo.com
PTR No. 065475, 1/3/2010
IBP No. 01258, 1/3/2010
MCLE No. 1452632

Doc. No. 200

Page No. 400
Book No. 152
Series of 2016

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