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Republic of the Philippines

Office of the Secretary
Padre Faura St., Ermita, Manila


- versus - for
x - - - - - - - - - - - - - - - - - - - - - - -x


COMES NOW, the undersigned petitioner, unto this Honorable Office respectfully avers:

1. That on _________ the undersigned Chief of Police of ___(state the unit and postal address)___ upon
complaint of the private offended party filed a case against ___(state the name and postal address of the
respondent)__ for __(designation of offense) _ docketed under IS No. ____ before the Office of Honorable _________
located in ______ where the preliminary investigation took place;

2. That for the information of the Honorable Secretary this case started __(give the concise facts of the case)___

3. That on _____(date)___ the undersigned received the Resolution of the Honorable Prosecutor copy of which is
attached as Annex “A” disposing the case as follows:

Note: Copy the dispositive portion of the resolution.

4. That the undersigned ______(give your analysis how the Prosecutor disposed the case) ___.

5. That with due respect to the Honorable Prosecutor, the undersigned believed that he committed error on the

Note: Cite the matters that adversely affect your case

specifically pinpointing the law that supports your position

6. Attached as integral part of this petition are the following:

a) Proof of service of this Petition to the Honorable Prosecutor (Annex “B”)

b) Proof of service of this Petition to the Appealee
c) Other Records of the Case

WHEREFORE, the undersigned respectfully prays for the setting aside of the appealed resolution of Prosecutor
__________ dated _____and that the honorable prosecutor be directed to fileinformation ____(cite the relief that you
want if you have any)_____

Other reliefs just and equitable are likewise prayed for.

____Place________. ____Date_____.

Chief of Police



Copy furnished:
- Prosecutor
- Respondent

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