Republic of the Philippines

Department of Justice
National Prosecution Office
PROVINCIAL PROSECUTION OFFICE
______________________

INVESTIGATION DATA FORM

To be accomplished by the Office

DATE RECEIVED: NPS DOCKET NO.: NPS-V-09-INV____________

(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: RESPONDENT:
Name, age, address_____________________ _____________________________________
LAW VIOLATED: WITNESS:
____________________________________ _____________________________________

DATE AND TIME OF COMMISSION: PLACE OF COMMISSION:

__________________________________ _____________________________________

1. Has a similar complaint been filed before any other office? Yes ____ No ___
2. Is this complaint in the nature of a counter-affidavit? Yes ____ No ___
3. Is this complaint related to another case before the office? Yes ____ No ___

I.S. No.: __________________________________

Handling Prosecutor: _______________________

CERTIFICATION

WE CERTIFY, under oath that all information on this sheet are true and correct to the best
of our knowledge and belief, that we have not commenced any action or filed any claim involving
the same issue in any court, tribunal, or quasi-judicial agency, and that if we should thereafter learn
that a similar action has been filed and or is pending, we shall report that fact to this Honorable
Office within five (5) days from knowledge thereof.

_______________________________

SUBSCRIBED AND SWORN to before me this __th day of _____________ in

___________________, Philippines by _____________________________ who has satisfactorily
proven to me their identity through their _______________________________ and, that they are the
same persons who executed the foregoing and that they freely and voluntarily executed the same.

Doc. No. ___

Page No. ___
Book No. ___
Series of ____.