Republic of the Philippines

Department of Justice
OFFICE OF THE CITY PROSECUTOR
QUEZON CITY

INVESTIGATION DATA FORM

DATE RECEIVED NPS DOCKET NO

(stamped and initiated): __________ XV-03-19-INV______-________
Time Received: ________________ Assigned to: ________________________
Receiving Staff: _______________ Date Assigned: _____________

COMPLAINANT/S: (Name/Sex/Age/ RESPONDENT/S: (Name, Sex, Age & Address/es)

Address/es)
________________________________ _________________________________
________________________________ _________________________________
________________________________ _________________________________

OFFENSE/S COMMITTED/ LAW/S WITNESS/ES: NAME & ADDRESS/ES

VIOLATED (for cases of estafa, theft,
malicious mischief and RIRIDTP indicate
amount involved)
_________________________________ _________________________________
_________________________________ _________________________________
_________________________________ _________________________________

DATE & TIME OF COMMISSION PLACE OF COMMISSION

_____________________________ _____________________________

1. Has a similar complaint filed before any officer? YES __ NO __

2. Is this complaint in the nature of a counter-affidavit? 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 FI CAT I O N

I CERTIFY, under oath, 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 I should thereafter learn that a similar action has
been filed and or 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