NPS Investigation Form No. 01 s.

2011

Republic of the Philippines

Department of Justice
National Prosecution Service, Region 4
OFFICE OF THE PROVINCIAL PROSECUTION
Taytay, Rizal

INVESTIGATION DATA FORM

To be accomplished by the Office:

DATE RECEIVED: NPS DOCKET NO:

(stamped and initialled): __________________ _______________________________________

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

SOUTHERN FILLERS CORPORATION rep. by MAVRICK C. CAFIRMA

Karen Q. Sernero Male, legal age
Female, legal age, married ____, Binangonan, Rizal
054 National Road
Calumpang Binangonan, Rizal
WITNESS/es: Name & Address

OFFENSE/s COMMITTED / LAWS VIOLATED:

Camille Grace DM Bation, Mark Joseph L.
Violation of Art. 310 in rel to Arts. 308 and 309 of the Cervantes, Wilfredo Mira, Arjay Villadares,
Revised Penal Code National Road, Barangay Calumpang,
Binangonan, Rizal

DATE & TIME of COMMISSION: PLACE of COMMISSION:

September 12, 2020 Binangonan, Rizal

1. Has a similar complaint been filed before any other office? Yes ___ No _X_
2. Is this complaint in the nature of counter-charge? Yes ___ No _X_
3. Is this complaint related to another case before this office? Yes ___ No _X_
CERTIFICATION

I CERTIFY, under oath, that 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 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.

Karen Q. Sernero
Complainant

SUBSCRIBED AND SWORN TO before me this __th day of ___________, 2020 here at Taytay,
Rizal.

________________________________
Assistant Provincial Prosecutor