REPUBLIC OF THE PHILIPPINES

PRAYER
_______________________________
WHEREFORE, complainant respecully prays judgment for: _______________________________

COMPLAINT FORM
1. Order respondent to cease and desist from performing any act prohibited under JMC 2010-01; 1. The Personal circumstances of the pares are as follows:
Name of Name of
2. Impose the administra)ve penalty for viola)on of JMC 2010-01 including the accessory penal)es; Complainant: Respondent:

3. Grant all other reliefs allowed by law.

Sex: Sex:

City of ___________________________, _______ of ___________, 20_____. Age: Age:

Civil Status: Civil Status:
___________________________ Home Posion:
Complainant Address:
Office:

2. Complainant claims that Respondent violated any of the prohibions under the JMC 2010-01 (please check):

Unnecessary Interac)on with the Tobacco Industry

Verificaon and Cerficaon of Non-Forum Shopping
Preferen)al treatment to the Tobacco Industry
Accep)ng Gi/s, Dona)ons and Sponsorship from the Tobacco Industry
I, ______________________________________________________, of legal age, a/er having been duly
sworn in accordance with law, depose and state that: Having financial interest in the Tobacco Industry
Accep)ng other favors from the Tobacco Industry

1. I am the complainant in the above-stated case and I have caused the prepara)on of the foregoing Having a conflict of interest with the Tobacco Industry
complaint. Engaging in an occupa)onal ac)vity within the Tobacco Industry
2. I have read the contents thereof and the facts stated therein are true and correct of my personal 3. (A) Based on your personal knowledge or available facts on record, narrate the relevant and material facts
knowledge and/or on the basis of copies of documents and records in my possession; in detail which led you to believe that there was a violaon of JMC 2010-01:

3. I have not commenced any other ac)on or proceeding involving the same issues in the Supreme
Court, the Court of Appeals, or any other tribunal or agency;
(B) When did the violaon of the JMC 2010-01 occur
4. To the best of my knowledge and belief, no such ac)on or proceeding is pending in the Supreme
Court, the Court of Appeals, or any other tribunal or agency; (C) If no specific date, give the me period:
Date started:________________ Through: ________________
5. If I should therea/er learn that a similar ac)on or proceeding has been filed or is pending before the
4. (A) What is your proof that respondent violated any of the prohibions under JMC 2010-01 (please check)?
Supreme Court, the Court of Appeals, or any other tribunal or agency, I undertake to report that fact
Memorandum of Agreement/Understanding and other Agreements between the
within five (5) days therefrom to the Civil Service Commission.
Tobacco Industry and the Agency Concerned
Pictures of the Government Officers together with Tobacco Industry
_____________________________ Representa)ves
Affiant LeBers from/to the Tobacco Industry
Financial documents showing receipt of funds from Tobacco Industry
Subscribed and sworn to before me this __________ day of ________, 20______. Statements of Assets, Liabili)es and Net worth (SALN)
Employment/Consultancy Contract
Others_____________________________________________________
NOTARY PUBLIC
(B) Did you a<ach your proof to this form? Yes No