Doc.

Control No __________

INITIAL COMPLAINT FORM

COMPLAINANT
Name:
(Title/ Prefix) (First Name) (Middle Name) (Last Name) (Suffix)
Address
:
(House/Building No./Building Name) (Street Name) (Barangay)

(City/Municipality) (Province) (Region) (Zip Code)

E-mail: Tel/Cel #:
Social Classification:  Senior Citizen  Youth (15-30)  Out of School Youth Sex:  Male  Female
 Abled  Differently Abled  Indigenous Person
RESPONDENT
Name of Establishment:
Name of Owner/
Representative: (Title/ Prefix) (First Name) (Middle Name) (Last Name) (Suffix)
Address of Establishment:
(House/Building No./Building Name) (Street Name) (Barangay)

(City/Municipality) (Province) (Region) (Zip Code)

E-mail: Tel/Cel #:

Date of Consumer Transaction/Discovery: ________________________________________________________

Brief Narration of Facts:

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Documents Submitted: ________________________________________________________________________

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Relief Demanded:  Repair  Replace  Refund
 Others ___________________________________________________________

IN WITNESS WHEREOF, I have hereunto set my/our hand/s this day of 20 , in

, Philippines.

______________________
Complainant

All personal data collected herein shall be processed according to the principles and provisions of the Data
Privacy Act of 2012 (DPA), its Implementing Rules and Regulations (IRR), and National Privacy Commission
(NPC) issuances.

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(Signature over Printed Name of Authorized Signatory)