Republic of the Philippines

OFFICE OF THE PROVINCIAL PROSECUTOR

Batangas City
INVESTIGATION DATA FORM

  To be accomplished by the Office

DATE RECEIVED__________________     NPS. DOCKET No.:_________________
Handling Prosecutor:__________________(Stamped and initialed):____________
Time Received      :___________________  Assigned to:___________________
Receiving Staff     :___________________   Date Assigned:___________________
To be accomplished by complainant/counsel/law enforcer
(Use back portion if space is not sufficient)
 
COMPLAINANT/S: Name, Sex, RESPONDENT/S: Name, Sex, Age &
Age & Address Address
PSSg Ricardo De Leon Dalisay, Alvin Patrimonio y Gutierrez alias Tangkad,
male, 30 years old, married, male, 29 years old, born on December 4, 1994
member of Nasugbu MPS- married, construction worker, resident of
09351234567 Barangay Palanan, Nasugbu, Batangas
(arrested)

LAW VIOLATED
Violation of Art. II Sec. 5 and
11 of RA 9165
DATE & TIME of COMMISSION:                     PLACE of COMMISSION:
January 21, 2023 / 5:45 PM
WITNESS/ES; Name & Address
PCPT ROMNICK CRUZ SARMIENTO, male,
legal age, member of Nasugbu MPS
PCpl Miles Aquino Cruz, female, legal age,
member of Nasugbu MPS
PSSg Redford Palma Ortega, male, legal age,
member of Nasugbu MPS
Paolo Avelino Contis, male, legal age,
resident of Brgy. Asuncion, Nasugbu,
Batangas
Herbert Bautista Martinez, male, legal age,
resident of Brgy. Palanan, Nasugbu,
Batangas
Barangay Palanan, Nasugbu, Batangas

1. Has a similar complaint been filed before any other office?*   YES ______ NO
__/_
2. Is this complaint 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.  
                                                                        
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 commented any
action or filed any claim involving the same issues in any court, tribunal, or
quasijudicial agency, and that if I should thereafter learn that a similar action has
been filed and/or is pending, I shall report that the fact to his Honorable Office
within five (5) days from knowledge thereof.

PSSg Ricardo De Leon Dalisay

(Complainant)

SUBSCRIBED AND SWORN TO before me this ____ day of January 2023 at

Batangas City.