Republic of the Philippines

Department of the Interior and Local

Government
PHILIPPINE NATIONAL POLICE
Bulacan Police Provincial Office
Malolos Police Station

Date: 11/23/2022

COMPLAINT SHEET

Name of Suspects:
Jay B. Manalo
Last Known Address:
793 Bonifacio St. Brgy. Ligas City of Malolos, Bulacan
Nature of Offense:
Carnapping
Place Where Offense was Committed:
3015 Calle Lily Brgy. Bungahan City of Malolos, Bulacan
Date/Time Offense was Committed:
November 23, 2022 on or about 8:00 in the evening
Local Police Office First Reported:
Malolos Police Station
Date Reported:
11/23/2022

Brief Statement of Complaint sketch

According to the complainant, when he went
outside to buy Food in the fast food restaurant; He
couldn't find his motorcycle then the only left
behind is the motorcycle cover, broken padlock
and open gate.
Description of the Motor Vehicle
Make/Type Year Model Color
Honda Wave 2013 Blue & Black
Plate Number Chassis Number Engine Number
xxxxxx xxxxxx xxxxxx
M V File Number Registered Owner Address
xxxxxx Dalisay B. Rosas 3015 Calle Lily Brgy. Bungahan City
of Malolos, Bulacan

CERTIFICATION

I, Dalisay B. Rosas, after having been duly sworn to in accordance to law do hereby depose and say:That
I am the complainant of the aforesaid complaint;That I have read the essence and signed the same;That
all the allegations contained herein are true and correct to the best of my knowledge and hereby
warrant under penalty of perjury and;That I will immediately inform the PNP-HPG in case the
above described motor vehicle is recovered (by us) so that alarm could be lifted.

Confirmed By: ______ Dalisay B. Rosas _____ ___ Dalisay B. Rosas__

(Registered Owner) (Driver)

Address: 3015 Calle Lily Brgy. Bungahan City of Malolos,

Bulacan

Tel/Cell No. xxxxxxxxx___

SUBSCRIBED AND SWORN to before me this 23 day of November., affiant exhibited to me his/her
Residence Certificate No. xxxx issued at Cavanas on November 24, 2022.

_________________

(Notary Public)
 Note:Person found guilty of perjury is liable under Art.
183 of the Revised Penal Code

Republic of the Philippines

Department of the Interior and Local
Government
PHILIPPINE NATIONAL POLICE
Bulacan Police Provincial Office
Malolos City Police Station

ALARM SHEET
Alarm No. Date Reported Time Reported Date Lost Time Lost
08 11/23/2022 8:54 pm 11/23/2022 8:00 pm
Motor Vehicle Description
Make Series Year Model Body Type
Honda Wave 1 2013 [ ] AUV [ ] Jeepney [ ] HSPUR
[ ] Car [ ] Bus [ ] 3 Wheeled
Classification Engine No.
[ ] Wagon [ ] Utility Van [√] Motorcycle
[√ ] Private xxxxxx
[ ] Pick Up [ ] Truck [ ] Others:
[ ] For Hire
[ ] Closed Van [ ] Dropside ____________
[ ] Government Chassis No.
[ ]Diplomat xxxxxx
Plate No. Color MV File No. MVRR No. CR No.
xxxxxx Blue & Black xxxxxx xxxxxx xxxxxx
Owner Description
Registered Owner Last name First Name Middle Name Telephone NO.
Rosas Dalisay Batongbakal
Land line # xxxxxx
Mobile # xxxxxx
Address Type of ID Presented ID Number Presented
3015 Calle Lily Brgy. Bungahan City of Malolos, National ID xxxxxx
Bulacan
Insurer Tel No. Classification
Honda Company xxxxxx [√]TPL
[ ]Comprehensive
 CIRCUMSTANCES
Mode of Loss Brief Narration
[ ] Seized at Gunpoint/Intimidation According to the complainant, when he went outside to
[ ] Seized While Parked Unattended buy Food in the fast food restaurant; He couldn't find his
[ ] Qualified Theft motorcycle then the only left behind is the motorcycle
[ ] Theft cover, broken padlock and open gate.
[ ] Fraud
[ ] Estafa
[ ] Others _____________________
Reported By: [ ] W ITH SAFETY DEVICE
Dalisay B. Rosas [ ] ACTIVATED
[ ] NOT ACTIVATED
[√] MANUAL
Investigated By: [ ] ELECTRONIC
Spo 1 Conrado A. Tolentino [ ] GSP
[√ ] W ITHOUT SAFETY DEVICE

Approved By
Acting chief Jasinto C. Baltasar 2x3
Picture
With signature and
Thumb mark
 Republic of the Philippines
Department of the Interior and Local
Government
PHILIPPINE NATIONAL POLICE
Bulacan Police Provincial Office
Malolos City Police Station

REQUEST FOR LIFTING OF ALARM

Name of Applicant: _________________________________________________

Address: _________________________________________________
Registered Owner _________________________________________________
Address: _________________________________________________

Description of Motor Vehicle:

Make/Type/Yr Model: _________________________________________________

Color: _________________________________________________
Motor Number: _________________________________________________
Chassis Number: _________________________________________________
Plate Number: _________________________________________________

In connection with my request. I hereby submit the following:

( )Motor Vehicle for macro-etching examination
( )Alarm Sheet
( )Spot Recovery Report
( )Turn-Over/ Release Receipt of MV to owner by the covering PNP van. (if MV was recovered by
other PNP Units)()Original Official Receipt (OR) & Certificate of Registration (CR) if Xerox/photo copy, it
must be authenticated by C, Inves-OADI, investigator,/processing officer.
( )Deeds of Sale (If motor vehicle is not registered in the name of the applicant/ present owner)
( )Release of claim/subiogation/Deeds of Sale (if the applicant is an insurance company.
( )Special Power of Attorney (if applicant is a representative)
( )Affidavit of requesting Party/Owner that she/he is still theregistered owner and she/ he has not
made any claim with any insurance company re-loss of said MV
( )If MV was submitted/cited as evidence in a case filed in court, an order of release from court/ fiscal
( )taking cognizance of the case.
( )Others
___________________________ Signature

PHOTO
___________________________ Printed Name
___________________________
Driver’s License Number