Republic of the Philippines

Department of Justice
National Prosecution Service
OFFICE OF THE CITY PROSECUTOR
QUEZON CITY

INVESTIGATION DATA FORM

To be accomplished by the Office
DATE RECEIVED
NPS DOCKET NO.
(stamped and initiated): _________________________
XV-03-INV-16___-____________________
Time Received: _______________________________
Assigned to: __________________________
Receiving Staff: _______________________________
Date Assigned: ________________________
___________________________________________________________________________________________
To be accomplished by complainants/counsel/law enforcer
(Use back portion if space is not sufficient)
COMPLAINANT/S: Name, Sex, Age &
Address
JERALD B. ORTIZ, Male, of legal age, and
with work address at Unit 2A38 Grand
Shaw Boulevard, Barangay Highway Hills,
Mandaluyong City

RESPONDENT/S: Name, Sex, Age &

Address
LIEZEL MOLION, BENEDICT
HAMOR, both of legal age, and with
Kubayan, Casisang, Malaybalay City, and
122 B Natividad St, Caloocan City, respectively.

OFFENSE/s COMMITTED/LAW/s VIOLATED

ESTAFA under Article 315 of the Revised Penal Code
in relation to Presidential Decree No. 1689 and for
such other Crime that maybe derived From the facts.

WITNESS/es: Name & Address

_______________________________________
_______________________________________
_______________________________________

DATE AND TIME of COMMISSION:

Sometime in October 2015.

PLACE of COMMISSION:
Quezon City

1.
2.

Has a similar complaint been filed before any other Office?*

Is this complaint in the nature of a counter-affidavit?*
If yes, indicate details below.
3.
Is this complaint related to another case before this office?*
If yes, indicate details below.

YES ______ NO ______

YES ______ NO ______
YES ______ NO ______

I.S./NPS Docket No.: ______________________________________

Handling Prosecutor: ______________________________________

C E R T I F I C AT I O N
I CERTIFY, under oath, all the 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 I should thereafter learn that a similar action has been filed
and/or in pending, I shall report that fact to this Honorable Office within five (5) days from knowledge thereof.
_________________________
JERALD B. ORTIZ
SUBSCRIBED AND SWORN TO before me this _____ day of July, 2016, in Quezon City.
__________________________________
Administering Prosecutor/Officer
*1, 2,3 and CERTIFICATION need not be accomplished for inquest cases