Republic of the Philippines

Department of Justice
NATIONAL PROSECUTION SERVICE
Office of the City Prosecutor
Paranaque City

INVESTIGATION DATA FORM

To be accomplished by the Office:

DATE RECEIVED: NPS DOCKET NO.

(stamped and initiated):_________________________ XV-07-INV - ________________________
Time Received: _________________________ Assigned to: ________________________
Receiving Staff: __________________________ Date Assigned:________________________

To be accomplished by the complainant / counsel / law enforcer

(Use back portion if space is not sufficient)

COMPLAINANT/s: Name, Sex, Age & Address RESPONDENT/s: Name, Sex, Age & Address

By. John Karlo P. Fernandez SPS. ROMEO C. RUBIBIS and MARILYN

4011 E.Oca St. Barangay Nanhaya RUBIBIS of legal ages, and with address at Block
Victoria Laguna 8, lot 23, Coral Loop St., Westborough Severino Homes
Km 18, Marcelo Green, Paranaque City.

WITNESS/es: Name & Address

OFFENSE/s COMMITTED / LAW/s VIOLATED:
John Karlo P. Fernandez
Removal /Sale of Chattel 4011 E.Oca St. Barangay Nanhaya
Violation of RPC article 319 Victoria Laguna

DATE & TIME OF COMMISSION: PLACE OF COMMISSION

August 24, 2015
Paranaque City

1. Has a similar complaint been filed before any other office? YES___ NO
2. Is this complaint in the nature of a counter-charge? YES___ NO , if yes, indicate details below
3. Is this complaint related to another case before this office? YES___ NO

I.S. / NPS Docket No. ___________________

Handling Prosecutor ___________________

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 commenced any action or filed any claim involving the same issues in any court, tribunal, or quasi-
judicial agency, and that if I should learn that a similar action has been filed and/or is pending, I shall report that fact to this
Honorable Office within five (5) days from knowledge thereof.

JOHN KARLO P. FERNANDEZ

SUBSCRIBED AND SWORN TO BEFORE ME this November ___, 2017 in Paranaque City, Philippines.

______________________
Administering Officer

*1,2,3 and CERTIFICATION need not be accomplished for inquest cases.