Republic of the Philippines

Department of Justice
NATIONAL PROSECUTION SERVICE
Antipolo City, Rizal

INVESTIGATION DATA FORM

To be accomplished by the office

DATE RECEIVED: NPS DOCKET NO.: ________________

(Stamped and Initialed):_______________________ Assigned to : _________________
Time Received : _______________________ Date Assigned: ________________
Receiving Staff : _______________________

To be accomplished by complainant/counsel/law enforcer

(Use back portion if not sufficient)

COMPLAINANT/s Name, Sex, Age & Address RESPONDENT/s Name, Sex, Age & Address

1.Rose Alain y Robis, Female, 49 y.o, a resident of No.
1 Kalye Putol Sitio Tagbak Brgy. San Jose, Antipolo City
CP number:099999999
1. EDGARDO SANTIAGO y TADAS alyas “Tata Edgie”,
Male,57 years old,a native of Brgy. Malinis, Tuguegarao
City, Province of Cagayan, Cagayan Valley and
presently residing at No. 20 Sitio, Buhanginan, Brgy. San
Jose Antipolo City

2. Espinoza, Clark y Rulloda alyas Buli 50 years old,

Male, a native of Tuguegarao City, Province of Cagayan
Cagayan Valley and presently residing at No. 20 Sitio,
Buhanginan, Brgy. San Jose Antipolo City

3. Godoy, Jomar Bancifra alyas Suob, 54 years

old,Male a native of Tuguegarao City, Province of
Cagayan, Cagayan Valley and presently residing at No.
20 Sitio, Buhanginan, Brgy. San Jose Antipolo City

4. Liwaliw, Fronstone Campilis alyas ponkan, 55 years

old,Male, native of Tuguegarao City Province of
Cagayan, Cagayan Valley and presently residing at No.
20 Sitio, Buhanginan, Brgy. San Jose Antipolo City.

OFFENSE/s COMMITTED/LAW/s VIOLATED: Witness/s: Name & Address

Rape with Homicide Johnry Poblete y Duenas 49 years old, taho vendor, a
resident of Kalye Putol No.8 Sitio Tagbak Brgy. San
Jose, Antipolo City

TIME of COMMISSION: PLACE of COMMISSION:

transpired at about 10:00 A.M at Kalye Putol Sitio Tagbak Brgy. San Jose, Antipolo City

1. Has a similar complaint been filed before any other office? * YES___ NO_X__
2. Is this complaint in the nature of a counter – affidavit? * YES___ NO_X__
If yes, indicate details below.
3. Is this complaint related to another case before this office? * YES___ NO_X__

I.S. No.:___________________________________

Handling Prosecutor: ____________________

CERTIFICATIONS

I CERTIFY, under oath, that all information on this sheet are true and correct to the best of my knowledge
and belief, that I have not commence 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, shall
report that fact to this Honorable Office within five (5) days from knowledge thereof.

Rose Alain y Robis

Complainant

SUBSCRIBE AND SWORN TO before me this day of May 2013 in Antipolo City, Rizal.

____________________________
Administering Office/Prosecutor