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NPS Investigation Form No. 01 s.

2012

Republic of the Philippines


Department of Justice
NATIONAL PROSECUTOR SERVICE
OFFICE OF THE PROVINCIAL PROSECUTOR
ILAGAN CITY, ISABELA

INVESTIGATION DATA FORM


To be accomplished by the office:

DATE RECEIVED: NPS DOCKET NO.:

(stamped and initialed): ____________________________ ______________________________________


Time Received: _________________________________ Assigned to: ___________________________
Receiving Staff: _________________________________ Date Assigned: _________________________

To be accomplished by complainant/counsel/law enforcer:


(Use back portion if space is not sufficient)
COMPLAINANT/s: Name, Sex, Age & Address RESPONDENT/s: Name, Sex, Age & Address
DERRICK M. VIZCARRA; MALE 35; 51 National JASMIN I. VIZCARRA, FEMALE 34; Unit 103,
Highway, Bugallon Proper, Ramon Isabela Lilliane Building, Barangay Sta. Lucia, Dasmariñas,
Cavite;

OFFENSE/s COMMITED / LAW/s VIOLATED: WITNESS/es: Name & Address

Violation of Section 4(c) (4) of Republic Act


10175 otherwise known as Cybercrime DERRICK M. VIZCARRA.
Prevention Act of 2012 and Libel under Article OTHER
353 in relation to Article 355 of the Revised
Penal Code

DATE & TIME COMMISSION: PLACE of COMMISSION:


MAY, 2016 RAMON, ISABELA

1. Has a similar complaint been before any other office?* YES ___ NO ___
2. Is this complaint in the nature of a counter-charge?* YES ___ NO ___ If yes, indicate details below
3. Is this complaint related to another case before this office?* YES ___ NO ___ If yes, indicate details below:
I. S. / NPS Docket No.: ________________________________
Handling Prosecutor: _________________________________

C E R T I F I C A T I O N*

I, CERTIFY, under oath, that all the information on this sheet are true and correct to the best 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 ________________________, 20____,


in _____________________________________________.

______________________________________
Administering Prosecutor / Officer
*1, 2, 3 and CERTIFICATION need be accomplished for inquest cases
NPS Investigation Form No. 01 s. 2012
Republic of the Philippines
Department of Justice
NATIONAL PROSECUTOR SERVICE
OFFICE OF THE CITY PROSECUTOR
SANTIAGO CITY

INVESTIGATION DATA FORM


To be accomplished by the office:

DATE RECEIVED: NPS DOCKET NO.:

(stamped and initialed): ____________________________ ______________________________________


Time Received: _________________________________ Assigned to: ___________________________
Receiving Staff: _________________________________ Date Assigned: _________________________

To be accomplished by complainant/counsel/law enforcer:


(Use back portion if space is not sufficient)
COMPLAINANT/s: Name, Sex, Age & Address RESPONDENT/s: Name, Sex, Age & Address
ILUMINADA P. LAMPA, - Female’________________ MICHAEL B. PERALTA, -Male,__________________
Resident of Brgy. Rizal East, San Isidro, Isabela. Resident of No. 45 Recto Street, Centro West,______
___________________________________________ Santiago, City ______________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________

OFFENSE/s COMMITED / LAW/s VIOLATED: WITNESS/es: Name & Address


RECKLESS IMPRUDENCE RESULTING TO _______ 1. ILUMINADA P. LAMPA, - Rizal East, San Isidro, Isa.
HOMICIDE defined and penalized under Article 365_ 2. TOMNICOLAS P. LAMPA, - Rizal East, San Isidro,_
Of the Revised Penal Code_____________________ ___Isabela_________________________________
___________________________________________ 3.SPO4 MACARIO P. DUMAG, - Investigator_______
___________________________________________ 4. Others ___________________________________
DATE & TIME COMMISSION: PLACE of COMMISSION:
NOVEMBER 07, 2010_________________________ SANTIAGO CITY_____________________________
___________________________________________ __________________________________________

1. Has a similar complaint been before any other office?* YES ___ NO ___
2. Is this complaint in the nature of a counter-charge?* YES ___ NO ___ If yes, indicate details below
3. Is this complaint related to another case before this office?* YES ___ NO ___ If yes, indicate details below:
I. S. / NPS Docket No.: ________________________________
Handling Prosecutor: _________________________________

C E R T I F I C A T I O N*
I, CERTIFY, under oath, that all the information on this sheet are true and correct to the best 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.

ILUMINADA P. LAMPA
(Signature over printed name)

SUBSCRIBED AND SWORN TO before me this ______ day of ________________________, 20____,


in _____________________________________________.

______________________________________
Administering Prosecutor / Officer
*1, 2, 3 and CERTIFICATION need be accomplished for inquest cases
NPS Investigation Form No. 01 s. 2012
Republic of the Philippines
Department of Justice
NATIONAL PROSECUTOR SERVICE
OFFICE OF THE PROVINCIAL PROSECUTOR
CAUAYAN CITY, ISABELA

INVESTIGATION DATA FORM


To be accomplished by the office:

DATE RECEIVED: NPS DOCKET NO.:

(stamped and initialed): ____________________________ ______________________________________


Time Received: _________________________________ Assigned to: ___________________________
Receiving Staff: _________________________________ Date Assigned: _________________________

To be accomplished by complainant/counsel/law enforcer:


(Use back portion if space is not sufficient)
COMPLAINANT/s: Name, Sex, Age & Address RESPONDENT/s: Name, Sex, Age & Address
___________________________________________ __________________________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________

OFFENSE/s COMMITED / LAW/s VIOLATED: WITNESS/es: Name & Address


___________________________________________ __________________________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________
___________________________________________ __________________________________________
DATE & TIME COMMISSION: PLACE of COMMISSION:
___________________________________________ __________________________________________
___________________________________________ __________________________________________

1. Has a similar complaint been before any other office?* YES ___ NO ___
2. Is this complaint in the nature of a counter-charge?* YES ___ NO ___ If yes, indicate details below
3. Is this complaint related to another case before this office?* YES ___ NO ___ If yes, indicate details below:
I. S. / NPS Docket No.: ________________________________
Handling Prosecutor: _________________________________

C E R T I F I C A T I O N*

I, CERTIFY, under oath, that all the information on this sheet are true and correct to the best 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 ________________________, 20____,


in _____________________________________________.

______________________________________
Administering Prosecutor / Officer
*1, 2, 3 and CERTIFICATION need be accomplished for inquest cases