Republic of the Philippines

Province of Davao Del Norte

Municipality of Santo Tomas
Barangay La Libertad

OFFICE OF THE SANGGUNIANG BARANGAY

BARANGAY BLOTTER
INCIDENT REPORT:

As per report and records of events available in the official barangay blotter of this office, there
appears the following data, to wit:

Barangay Blotter Series of : _________________

Blotter Page Number : _________________
Blotter Entry Number : _________________
Date & Time Entered : _________________

FACTS OF THE CASE:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Entered this _____ day of __________________, _________ at Barangay La Libertad, Santo

Tomas, Davao del Norte.

Prepared by:

KRIS D. SALVANERA
Barangay Secretary
Certified by:

FELIXBERTO V. ENRIQUEZ
Punong Barangay
 Republic of the Philippines
Province of Davao Del Norte
Municipality of Santo Tomas
Barangay La Libertad

OFFICE OF THE SANGGUNIANG BARANGAY

BLOTTER FORM

Blotter Date: ________________________

A. Name of Reporter/Complainant:
Address: _____________________________________________________________________
Contact No.: _________________________________________ Edad: ________

B. Name of the Respondent:

Address: _____________________________________________________________________
Contact No.: _________________________________________ Edad: ________

C. Complaint: ___________________________________________________________________

D. Description of Incident:
______________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
______________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Signature of Reporter: ________________________________

Name of Reporter: ___________________________________________________________
Date: _______________________________ Time: ___________