REPUBLIC OF THE PHILIPPINES)

*** CITY, ***) S.S

VERIFICATION AND CERTIFICATION

I, ***, of legal age, single, and a resident of *** City, after having
been sworn in accordance with law, do here depose and state:

1. That I am the complainant in the instant protest, being the

representative of (company name), and duly authorized by Board
Resolution No. ______;

2. That I have read all the allegations in this protest and the same are all
true and correct to the best of my knowledge and information;

3. That I did not commence any action or file any claim involving the
same issues in any court, tribunal or quasi – judicial agency, and to
the best of my knowledge and information, no such other action is
pending therein; and

4. That should I thereafter learn that the same or similar action or claim
has been filed or pending, I shall report that fact within five (5) days
therefrom, to this Honorable Board.

IN WITNESS WHEREOF, I have hereunto affixed my signature this ___ day

of July 2021 at *** City, Philippines.

***
Complainant

SUBSCRIBED AND SWORN to before me this ___ day of July 2021, affiant
exhibiting to me his _________ issued on _______ in ______.

NOTARY PUBLIC

Doc No.
Page No.
Book No.
Series of 2021.