Republic of the Philippines

Department of Justice
NATIONAL PROSECUTION SERVICE
OFFICE OF THE CITY PROSECUTOR
Passi City ,Iloilo

INVESTIGATION DATA FORM

DATE RECEIVED: NPS DOCKET NO:

(Stamped and Initialed}:
Time Received : Assigned To :
COMPLAINANT/s : Name, Sex, Age & Address RESPONDENTS/s Name, Sex, Age & Address
Joselito Mondejar ,male,45yrs old, Sitio Kabanatian 1. Jose Broniola Alias Asot 50 Sitio Kabanatian
Brgy. Tumanding, Arakan , otabato Brgy. Tumanding, Arakan, Cotabato

OFFENSE/s COMMITTED/LAW/s VIOLATED: WITNESS/es Name and Address:

Rape with Homicide

DATE & TIME of COMMISSION: PLACE of COMMISSION:
February 28,2000 Sitio Kabanatian Brgy Tumanding , Arakan,
Cotobato
______________________________________________________________________________________
1. Has similar complaint been filed before any other office? YES _____ NO _ /__
2. Is this similar complaint in nature of counter-charge? YES _____ NO __/__
3. Is this complaint related to another case before this office? YES _____ NO _/___
I.S. / NPS Docket No: ______________________________________
Handling Prosecutor

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 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.

JOSELITO MONDEJAR
Complainant

SUBSCRIBED AND SWORN to before me this __th day of February 2000, Philippines.