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Republic of the Philippines

PROVINCE OF ILOILO
OFFICE OF PROVINCIAL PROSECUTOR
Hall of Justice, Iloilo City
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INVESTIGATION DATA FORM

DATE RECEIVED NPS DOCKET NO:________________


(Stamped and initialed)_____________ Assigned to:_____________________
Timed Received:____________________ Date Assigned:___________________
Receiving Staff:______________________
To be accomplished by complainants/counsel/law enforcer
(Use back portion if space is not sufficient)

COMPLAINANT/S: RESPONDENT/S:
Name, Sex, Age & Address Name, Sex, Age & Address
, female, legal age, with address at Brgy. Igtuba, male, legal age and a resident of Bolho, Miag-ao
Miag-ao Iloilo Iloilo

OFFENSE/S COMMITED: Witness: Name & Address


LAWS VIOLATED
Violence against Women and their Children 1.
Through marital infidelity 2. Others (Reserved)

DATE & TIME OF COMMISSION: PLACE OF COMMISSION:


Iloilo

1) Has a similar complaint been filed before any other office?


Yes______ No_______
If yes, indicate details below.
__________________________________________________________________
2) Is this complaint in the nature of counter-charge?
Yes______ No_______
If yes, indicate details below.
__________________________________________________________________
3) Is this complaint to mother case before this office
Yes______ No______
If yes, indicate details below.
__________________________________________________________________

NPS Docket No._______________________________________


Handing 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 file any claim involving the same issues in any
court, tribunal or quasi-judicial agency and that if I should thereafter 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.
___________________________
MA. MILA DINSAY NEMIADA
Affiant

SUBSCRIBED AND SWORN to before me this ____ __________, in City of Iloilo, Philippines.

_________________________
Administering Prosecutor/Officer

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