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Republic of the Philippines

PEOPLES LAW ENFORCEMENT BOARD


Municipality of Palanan, Isabela

COMPLAINT SHEET

1. COMPLAINANT/S (nagsusumbong) Address and Tel/Cel


No/s.
______________________________ ________________________
______________________________ ________________________
______________________________ ________________________

2. PNP MEMBER/S COMPLAINED AGAINST or SUSPECT/S


(isinusumbong)
Rank and Fulname Unit/Assignment
______________________________ ________________________
______________________________ ________________________
______________________________ ________________________
_________________________________________________________________
Other information (iba pang impormasyon kaugnay sa isinusumbong)

3. NATURE OF ACT/S COMPLAINED OF (uri ng sumbong)


_________________________________________________________________

4. WHEN AND WHERE COMMITTED (kelan at saan nangyari)


_________________________________________________________________

5. VICTIM/S, IF ANY (iba pang biktima, kung mayroon)


Name Address and Tel/Cel
No/s.
______________________________ ________________________
______________________________ ________________________

6. BRIEF NARRATION OF FACTS (maiksing salaysay ng mga


pangyayari)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

PAGE TWO.
COMPLAINT SHEET.

7. HAS THE MATTER BEEN REPORTED TO ANY AGENCY?


(ang bagay bang ito ay naiulat na sa ibang sangay ng pagsisiyasat?)
______
IF SO, TO WHAT AGENCY?
(kung naiulat na, saang sangay?) ____________________________________

8. IS THE MATTER COMPLAINED OF A SUBJECT OF ANY COURT


ACTION OR
PROCEEDINGS? (ang bagay bang may kinalaman sa pagsusumbong
ay nasa
hukuman na?) _____________________________________________________
IF SO, WHERE?
(kung mayroon, saan?) _____________________________________________

I certify that the foregoing statements are true and correct


according to the best of my knowledge and information
(pinatutunayan ko ang buong katotohanan ng mga nakasaad ditto batay
sa aking nababatid at kaalaman)

RIGHT ______________________________
THUMBMARK
(signature over
printed name)

SUBSCRIBED AND SWORN to before me this ________ day of


___________________, 2019 in Palanan, Isabela.

______________________________
PLEB Member/Chairman
Administering Officer
(Sec. 1, Rule 23, NAPOLCOM MC. NO. 2016-002)
VERIFICATION AND CERTIFICATION

REPUBLIC OF THE PHILIPPINES )


PROVINCE OF ISABELA ) S. S.
MUNICIPALITY OF PALANAN )

THAT I, __________________________________________, after having been


duly sworn to in accordance with law, do hereby depose and state that:
1. I am the complainant herein above-named who caused the
preparation
of the foregoing complaint;
2. I have read and understood the contents thereof and that the
averments
contained therein are true and correct of my knowledge and
information;
3. I further certify under oath that:
a. if there is any such action or proceeding which is either
pending
or may have been terminated, I will state that status
thereof;
b. if I should thereafter learn that a similar action or
proceeding has
been filed or is pending before any other disciplinary
authority, I
will undertake to report such fact within five (5) days
therefrom to
the Honorable Commission.

IN WITNESS HEREOF, I have unto set my hand this ________ day of


__________________, 2019 at Palanan, Isabela.

______________________________
(complainant)
SUBSCRIBED AND SWORN to before me this ________ day of
___________________, 2019 in Palanan, Isabela.

______________________________
(Administering Officer)

Republic of the Philippines


NATIONAL POLICE COMMISSION
Regional Office No. 4-A CALABARZON
AUYONICK Building, National Highway, Parian, Calamba City
Tel. Fax No. (049) 545-1368

COMPLAINT SHEET

1. COMPLAINANT/S (nagsusumbong) Address and Tel/Cel


No/s.
______________________________ ________________________
______________________________ ________________________
______________________________ ________________________

2. PNP MEMBER/S COMPLAINED AGAINST or SUSPECT/S


(isinusumbong)
Rank and Fulname Unit/Assignment
______________________________ ________________________
______________________________ ________________________
______________________________ ________________________
_________________________________________________________________
Other information (iba pang impormasyon kaugnay sa isinusumbong)

3. NATURE OF ACT/S COMPLAINED OF (uri ng sumbong)


_________________________________________________________________

4. WHEN AND WHERE COMMITTED (kelan at saan nangyari)


_________________________________________________________________
5. VICTIM/S, IF ANY (iba pang biktima, kung mayroon)
Name Address and Tel/Cel
No/s.
______________________________ ________________________
______________________________ ________________________

6. BRIEF NARRATION OF FACTS (maiksing salaysay ng mga


pangyayari)
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________

_________________________________________________________________

PAGE TWO.
COMPLAINT SHEET.

7. HAS THE MATTER BEEN REPORTED TO ANY AGENCY?


(ang bagay bang ito ay naiulat na sa ibang sangay ng pagsisiyasat?)
______
IF SO, TO WHAT AGENCY?
(kung naiulat na, saang sangay?) ____________________________________

8. IS THE MATTER COMPLAINED OF A SUBJECT OF ANY COURT


ACTION OR
PROCEEDINGS? (ang bagay bang may kinalaman sa pagsusumbong
ay nasa
hukuman na?) _____________________________________________________
IF SO, WHERE?
(kung mayroon, saan?) _____________________________________________

I certify that the foregoing statements are true and correct


according to the best of my knowledge and information
(pinatutunayan ko ang buong katotohanan ng mga nakasaad ditto batay
sa aking nababatid at kaalaman)

RIGHT ______________________________
THUMBMARK
(signature over
printed name)
Attested by:

SPO1 JESUS L. CASTRO


Father/Guardian of Complainant

SUBSCRIBED AND SWORN tp before me this ________ day of


___________________, 2017 at the NATIONAL POLICE COMMISSION Regional
Office No. 4A (CALABARZON)

______________________________
(Administering Officer)

VERIFICATION AND CERTIFICATION

REPUBLIC OF THE PHILIPPINES )


PROVINCE OF LAGUNA ) S. S.
CITY OF CALAMBA )

THAT I, __________________________________________, after having been


duly sworn to in accordance with law, do hereby depose and state that:
1. I am the complainant herein above-named who caused the
preparation
of the foregoing complaint;
2. I have read and understood the contents thereof and that the
averments
contained therein are true and correct of my knowledge and
information;
3. I further certify under oath that:
a. if there is any such action or proceeding which is either
pending
or may have been terminated, I will state that status
thereof;
b. if I should thereafter learn that a similar action or
proceeding has
been filed or is pending before any other disciplinary
authority, I
will undertake to report such fact within five (5) days
therefrom to
the Honorable Comission.

IN WITNESS HEREOF, I have unto set my hand this ________ day of


__________________, 2017 at Calamba City (Laguna).

______________________________
(complainant)

Attested by:

JESUS L. CASTRO
Father/Guardian of Complainant

SUBSCRIBED AND SWORN tp before me this ________ day of


___________________, 2017 at the NATIONAL POLICE COMMISSION Regional
Office No. 4A (CALABARZON)

______________________________
(Administering Officer)

Fn: COMPLAINT SHEET


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