CERTIFICATION REGARDING LITIGATION, PROCEEDINGS AND INVESTIGATIONS
I, _______________________________________________, of legal age, Filipino, and with address at _________________________________________________________________, after being sworn in accordance with law, hereby state:
1.I am applying with Uber Systems, Inc. ("USI") for the following: [Check the applicable box]
Accreditation as Transportation Network Vehicle Service (TNVS) Accreditation as TNVS driver Accreditation of TNVS vehicle Issuance of Certificate of "Good Standing" as TNVS
2.Upon request of USI, I hereby certify as follows: [Check the applicable box. If you choose the lower box, please provide the required information at the end of this form.]
I have not been a party to any litigation or other proceedings, or the subject of any investigations (with or without a complaint being laid), whether completed or pending, whether civil, criminal, administrative or otherwise, before any court, tribunal, office, police, other law enforcement officer, or quasi-judicial agency in the Philippines.
I am/have been a party to the litigation/other proceedings or am/was the subject of the investigations described at the end of this form. [Describe the litigation/other proceedings/investigations in the space provided at the end of this form] 3.I hereby authorize USI, its Affiliates and/or related parties to: (a) verify the status of any litigation/proceedings/investigations herein described; and (b) to disclose any information I have provided, whether in this form or otherwise, whether provided before or after the date hereof, or that they may gather in connection with their subsequent verification of said information, to the LTFRB or other relevant court, agency, forum or other persons, as may be necessary for purposes of processing my above application or in connection with my being a TNVS, a driver of a TNVS or my TNVS vehicle.
4.Further, I am executing this Certification, to attest to the truth of the foregoing facts, voluntarily and with full knowledge and understanding that any false statement herein may subject me to applicable criminal and/or administrative liabilities under existing laws.
________________________________ Signature over printed name
DETAILS OF PENDING LITIGATION, PROCEEDINGS AND/OR INVESTIGATIONS
[Describe the litigation/other proceedings/investigations in the space below and in a separate sheet if necessary]
SUBSCRIBED AND SWORN to before me this ______ day of _______________________ 2015, at _______________ City, affiant exhibiting to me the following:
AffiantCompetent Evidence of IdentityCommunity Tax Certificate
Type of IDID No. and Expiry Date (if applicable)NumberDate and Place Issued
I further certify that I have personally examined the affiant and that I am satisfied that he understood and voluntarily executed this Certification.
NOTARY PUBLICDoc. No. ___;Page No. ___;Book No. ___;Series of 2015.3