Sample Format of Complaint Sheet (Other Crimes)

Republic of the Philippines

Department of the Interior and Local Government
PHILIPPINE NATIONAL POLICE
______________________________________
_______________________

COMPLAINT SHEET
Complaint No.________________
_________________

Date:

1. REPORTED THRU:
[ ] In Person
[ ] Telephone
[ ] Other

2. Previously Reported to other agency:

[ ] Yes [ ] No
If yes;
a. To what agency
_____________________________
b. BY whom
__________________________________
c. Date/time
__________________________________

3. Nature of Complaint/Info

4. Place of Occurrence/Incident

5. Date/time

6. Name of Complainant/Informer

7. Address

8. Tel No.

9. Name(s) of Victim(s)

10. Age

11.Sex

13. Tel No.

14. Name(s) of Suspect(s)

15. Alias

19. Name(s) of Witness(es)

12. Address

16.Sex 17.Age 18. Address

20. Address

21. Tel No.

22. Brief facts/narrative of complaint (Use back page, if necessary)

23. Remarks of the receiving officer (especially if reporter refused to be identified):

a. Dialect (Accent): ________________________________
b. Female/Male:
c. Possible Age: __________________________________
d. Possible place where the caller is: ____________________________________
e. Intoxicated or not: _________________________________________________
f. Others:: _________________________________________________________
24. I certify that the details of the
25. SUBSCRIBED AND SWORN to before
complaint/info stated above are true and
me this ____ day of April 2009 at Camp
correct to the best of my knowledge.
Crame, Quezon City.
____________________
______________ Printed Name & Signature of
Complainant/Informer

26. Date/Time/Complaint/Info Received

27. Printed name/Signature of Receiving

Officer

28. Assigned to:

29. Noted by:

CONFIDENTIAL