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Republic of the Philippines

Philippine National Police
National Capital Region Police Office
MANILA POLICE DISTRICT
CENTRAL MARKET STA. CRUZ POLICE STATION (PS-3)
BARBOSA POLICE COMMUNITY PRECINCT
Bautista St., Quiapo, Manila

DATE AND TIME REPORTED: _____________________________________________________________________

COMPLAINANT:
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(Surname) (Given Name) (Middle Name)

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(Age) (Sex) (Civil Status) (Contact No.)

COMPLETE ADDRESS:__________________________________________________________________________

SUSPECT/S NAME: _____________________________________________________________________________

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(Age) (Sex) (Civil Status) (Contact No.)

SUSPECT/S ADDRESS:___________________________________________________________________________

Date/Time/Place of Occurence:
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Brief Facts of the Case:

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Signature over printed name of the Complainant

SUBSCRIBED AND SWORN to before me this_______ day of _________ at Manila Police District
Headquarters, United Nations Avenue, Ermita, Manila.

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Administering Officer