REPUBLIC OF THE PHILIPPINES

DEPARTMENT OF JUSTICE
NATIONAL PROSECUTION SERVICE
OFFICE OF THE PROVINCIAL PROSECUTOR
PROVINCE OF ILOILO
Iloilo City

INVESTIGATION DATA FORM

To be accomplished by this Office

DATE RECEIVED: NPS DOCKET NO:

Stamped and Initiated: ______________________ _________________________

Time Received: ___________________________________________ Assigned to: _________________________
Receiving Staff: ___________________________________________ Date assigned: _______________________
_____________________________________________________________________________________________________
To be accomplish by the complainant/counsel/law enforcer:

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

__________________________________________
__________________________________________
__________________________________________
Contact No: ________________________________
_________________________________
__________________________________________
___________________________________________
___________________________________________
Contact No:

OFFENSE/s COMMITTED/ LAW/s VIOLATED WITNESS/es: Name & Address

_________________________________________ ___________________________________________
_________________________________________ ____________________________________________
_________________________________________ ____________________________________________
_________________________________________ ____________________________________________

DATE & TIME of COMMISSION: PLACE of COMMISSION:

_________________________________________ ____________________________________________
_________________________________________ ____________________________________________
: Has similar complaint been filed any other office? YES_____ NO__________
: Is this complaint in the name of a counter charge? YES________ NO_____if yes, indicate the details below
: Is this complaint related to another case before this office? YES_____ NO_____if yes, indicate the details below

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 file any claim involving the same issue 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.

__________________________________
( Signature over printed name)

SUBSCRIBED AND SWORN to before me this ______ day of ________________ 20___ .

__________________________________
Administering Prosecutor Officer

*1.2.3. and CERTIFICATION need to be accomplished for inquest cases.