FORM 1-A-SCC

VERIFICATION AND CERTIFICATION AGAINST NON-FORUM SHOPPING,

SPLITTING A SINGLE CAUSE OF ACTION AND MULTIPLICITY OF SUITS

I, Jose T. Gomez, of legal age, Filipino, married, and a resident of 175 Allarey st. Brgy.
7, Lucena City, on oath, state:

1. That I am the Plaintiff in the above-entitled case have caused this money 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 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
Lucena City; 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 10th day of November 2021.

Jose T. Gomez
Affiant

SUBSCRIBED AND SWORN TO before me this 10th day of November 2021.

NOTARY PUBLIC

Doc. No. _____

Page No. _____
Book No. _____
Series of 2021.