Philippine National Police

INCIDENT RECORD FORM

IRFENTRYNUMBER: TYPEOFINCIDENT: COPYFOR:
2022 - 002 SHOOTING INCIDENT
INSTRUCTIONS: Refer to PNPSOP on ͚Recording of Incidents in the Police Blotter͛ in filling up this form. This Incident Record Form(IRF) maybe reproduced, photocopied,
and/or downloaded from the DIDM website, www.didm.pnp.gov.ph.
DATEANDTIMEREPORTED: DATEANDTIMEOFINCIDENT: PLACEOFINCIDENT:
April 25,2022 7:00pm April 25,2022 6:30pm Brgy. Public Market, Bulanao,Tabuk
City,Kalinga
ITEM “A”-REPORTINGPERSON
FAMILYNAME FIRSTNAME MIDDLENAME QUALIFIER NICKNAME

CITIZENSHIP SEX/GEND CIVILSTATUS DATEOFBIRTH(MM/DD/YY) AG PLACEOFBIRTH HOMEPHONE MOBILEPHONE

CURRENTADDRESS(HOUSENUMBER/STREET VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

OTHERADDRESS(HOUSENUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION ID CARD PRESENTED EMAIL ADDRESS (If any)

ITEM “B”–SUSPECT’S DATA

FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME

CITIZENSHIP SEX/GEND CIVILSTATUS DATE O FBIRTH(MM/DD/YY) AG PLACE OF BIRTH HOME PHONE MOBILE PHONE
Married E

CURRENT ADDRESS (HOUSENUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

OTHER ADDRESS (HOUSENUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS RELATION EMAIL ADDRESS (If any)
TO
VICTIM
IF AFP/PNP PERSONNEL: RANK UNIT ASSIGNMENT GROUP AFFILIATION WITH PREVIOUS CRIMINAL RECORD? STATUS OF PREVIOUS CASE
[] Yes [] No
(If Yes, pls. specify)

HEIG WEIGHT BUILT COLOROFEYES DESCRIPTIONOFEYES COLOROFHAIR DESCRIPTIONOFHAIR UNDER THE INFLUENCE?
HT NO฀ DRUGS฀ LIQUOR
OTHERS

FORCHILDRENIN CONFLICTWITHTHELAW
NAME OF GUARDIAN GUARDIAN’s ADDRESS HOME PHONE MOBILE PHONE

ITEM “C”–VICTIM’SDATA
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME
Boy Negro
SANTOS ROLLY DIMAGIBA
CITIZENSHIP SEX/GEND CIVIL DATE OF BIRTH(MM/DD/YY) AG PLACE OF BIRTH HOME PHONE MOBILE/PHONE
FILIPINO M STATUS 01-05-70 E Bulanao,Tabuk City,Kalinga
Marrie 52 0917-694-7801
d
CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
Bulanao Kalinga
Purok1 Tabuk
City
OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS EMAIL ADDRESS (If any)
Public Market
COLLEGE LEVEL COLECTOR

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 ITEM “D”- NARRATIVEOFINCIDENT
TYPEOFINCIDENT DATE/TIME OF INCIDENT PLACE OF INCIDENT

SHOOTING INCIDENT April 25,2022 6:30 pm Brgy. Public Market, bulanao,Tabuk City, Kalinga
ENTER IN DETAIL THE NARRATIVE OF THE INCIDENT OR EVENT, ANSWERING THE WHO, WHAT, WHEN,WHERE,WHY AND HOW OF REPORTING.

ON/ABOUT APRIL 25, 2022 – 6:30PM, THERE IS A SHOOTING INCIDENT AT BRGY. PUBLIC MARKET, BUlANAO,
TABUK CITY, KALINGA. THE VICTIM ONE ROLLY DIMAGIBA SANTOS, COLLEGE LEVEL, COLLECTOR, MALE, MARRIED, BORN
ON JANUARY 5, 1970, 52 YEARS OLD, RESIDENT OF PUROK 1, BULANAO, TABUK CITY, KALINGA.THEY FOUND THAT THE
VICTIM WAS COLLECTING ADVANCE PAYMENT FROM ONE OF THEIR DEBTOR AND THE SUSPECT SHOT THE VICTIM, ROB HIS
BAG AND FLED IMMEDIATELY TOWARDS PUROK 5 EXIT TO BLOCK 3 BY RIDING A MOTOR-CYCLE WITHOUT PLATE NUMBER.
MANHUNT OPERATION IS STILL ONGOING. THE VICTIM FOUND 1 GUN SHOT WOUNDS, CHEST AND BROUGHT TO THE
ALMORA GENERAL HOSPITAL BY A CONCERNED CITIZEN.

I HEREBY CERTIFY TO THE CORRECTNESS OF THE NAME OF REPORTING PERSON SIGNATURE OF REPORTING PERSON
FORGOING TO THE BEST OF MY KNOWLEDGE AND
BELIEF.

NAME OF ADMINISTERING OFFICER SIGNATURE OF ADMINISTERING OFFICER (DUTY OFFICER)

(DUTY OFFICER)
SUBSCRIBED AND SWORN TO BEFORE ME

RANK, NAME AND DESIGNATION OF POLICE OFFICER (WHETHER HE/ SHE IS THE DUTY SIGNATURE OF DUTY INVESTIGATOR/INVESTIGATOR
INVESTIGATOR, INVESTIGATOR ON CASE OR THE ASSISTING POLICE OFFICER) ON CASE/ASSISTING POLICEOFFICER

PMSg NOVELYN V. LUMBOY

RANK/NAME OF DESK OFFICER: SIGNATURE OF DESK OFFICER: BLOTTER ENTRY NR:
INCIDENT RECORDED IN THE BLOTTER BY:
PEMS HERSHEYKRIS G. PIMENTEL 2018 – 002

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