COMPLAINT SHEET

(Fill up as completely as possible)

Reference Number_________
Docket Number_____________
Date Filed
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RANK/NAME OF RESPONDENT/S:______________________________________________

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UNIT ASSIGNMENT/ADDRESS:_________________________________________________

NATURE OF COMPLAINT: ____________________________________________________

TIME, DATE AND PLACE OF OCCURENCE : __________________________________

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NAME OF COMPLAINANT:____________________________________________________

ADDRESS:___________________________________________________________

CONTACT/TELEPHONE NUMBER: _____________________________________________

WITNESS ADDRESS TEL. NO.

1) ________________________________________________________________________

2) ________________________________________________________________________

3) ________________________________________________________________________

4) ________________________________________________________________________

DETAILS OF COMPLAINT

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I HEREBY CERTIFY that the foregoing statements are true and correct to
the best of my knowledge and belief. In witness hereof, I have hereunto
affixed my signature this _____ day of __________________, 201__ here at
Camp Crame, Quezon City, Philippines.

____________________________
(Signature of Complainant)

FINDINGS SUGGESTION/ACTION TAKEN:

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____________________________________________________________________
____________________________________________________________________

_____________________________________
 (Name and Signature of Interviewer)

CERTIFICATE OF NON-FORUM SHOPPING

I, ___________________________________________________, of legal
age and a resident of _________________________________________________
_________________________________________ under oath depose and state;

THAT, I am filing an administrative complaint against________________

____________________________________________________________________
____________________________________________________________________
a bonafide member of the Philippine National Police presently assigned at
______________________________________________ for ___________________
____________________________________________________________________
before this Office;

THAT, I had neither filed nor commenced any other action or

proceedings involving the same act or omission with any other administrative
authority of forum;

THAT, to the best of my knowledge, no such action or proceedings is

pending before any of such administrative authority;

THAT, if there is any such action or proceedings which is either pending

or may have been terminated, I must state the status thereof;

AND, that If I should thereafter learn that a similar action or proceedings

has been filed or is pending before any other administrative disciplinary
authority, I undertake to inform such act within five (5) days from such notice
to this Office or to the disciplinary authority wherein the original complaint or
pleading has been filed.

______________________
(Affiant)

SUBSCRIBED AND SWORN to before me this _____ day of

_____________ 201__ at Camp Crame, Quezon City, Philippines.
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Administering Officer