Republic of the Philippines

Department of Justice
National Prosecutor Service

OFFICE OF THE PROVINCIAL PROSECUTOR

Province of Cavite
Imus, Cavite

INVESTIGATION DATA FORM

To be accomplished by the Office

DATE RECEIVED:______________________
(Stamped and initiated)
Time Received: ________________________
Received Staff: ________________________

NPS DOCKET NO:IV-03-IN __-11____ - _______

Assigned To: ______________________________
Date Assigned:_____________________________

_______________________________________________________________________

To be accomplished by complainant/counsel/ Law Enforcer

(Use back portion if space is not sufficient)
COMPLAINANT/S:Name, sex, age and address
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

RESPONDENT/S: Name, sex, age and address

_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________

LAW/S VIOLATED:
_________________________________
_________________________________
_________________________________
_________________________________
_________________________________

WITNESS/ES: Name and address

_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________

DATE/ TIME OF COMMISSION

________________________________
________________________________

PLACE OF COMMISSION
_______________________________________
_______________________________________

1.
2.
3.

Has a similar complaint been filed before any office? Yes ___ No ____
Is the complaint in the nature of counter-affidavit? Yes ___ No ____ If yes, Indicate below
Is this complaint related to other case before this Office? Yes ____ No ____ If yes, Indicate below

I.S No. _______________________________________

Handling Prosecutor ____________________________

CERTIFICATION *
I CERTIFY, under oath, that all information on this sheet are true and correct to the best of my knowledge and belief,
That I have not commenced any action or filed any claim involving the same issues in any court, tribunal, or quasi-judicial
agency, and that if I should thereafter learn that a similar action has been filed and/or is pending, I shall report that fact to this
Honorable Office within five (5) days from knowledge thereof.

___________________________________

(Signature over printed name)

SUBSCRIBED AND SWORN to before
________________________________________________.

me

this

___

day

of

________2011,

__________________________________

Prosecutor/ Administering Officer

*1, 2, 3 and Certification need not be accomplished for inquest cases

in