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CONFIDENTIAL

INFORMATION REPORT
(PNP DI Form 004A)

1.FILE NUMBER
2.REFERENCE
3.SUBJECT
4.DATE OF REPORT
5.REPORTER
6.DESIGNATION/UNIT
7.EVALUATION
8.SOURCE OF INFORMATION
9.DATE ACQUIRED
10.MANNER ACQUIRED

11.INFORMATION PROPER:

12.COMMENT/s:

13.ACTION/s TAKEN/ TO BE TAKEN / REQUESTED:

14.ATTACHMENT/s:

SECURITY ADVICE: This document is for official and internal purposes only of the recipient and not for legal use. It is not to be
reproduced, copied, used in part or whole and disclosed or disseminated to another agency of third party without the consent of
the originator.

CONFIDENTIAL

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