Republic of the Philippines
Department of Justice
National Prosecution Service
Office of the City Prosecutor
Marikina City
To be accomplished by the Office
DATE RECEIVED ___________________ DOCKET NUMBER
Time Received ___________________ ________________________________
Receiving Staff ___________________ ASSIGNED TO ___________________
DATE ASSIGNED _________________
To be accomplished by the complainant/counsel/law enforcer (use back portion or additional
forms if necessary)
COMPLAINANT INFORMATION (Impormasyon ng Nagrereklamo)
Last name (Apelyido): Middle name (Gitnang Pangalan):
First name (Unang Pangalan): Alias (Alyas):
Date of Birth (Kapanganakan): Age(Edad): Corporation or Company being represented:
Sex: Citizenship:
⟤Male/Lalaki ⟤Female/Babae If foreigner indicate Passport or ACR. No.:
______
Civil Status Occupation:
⟤ Married ⟤ Single ⟤ Private ⟤ Government
⟤ Others (Pls Specify): ______________ ⟤ Others (Pls Specify): ______________
Present Address: Permanent Address:
Telephone/Mobile Number: E-mail Address:
Other Information:
⟤ Person with Disability Religion: ______________
⟤ Senior Citizen Other (Pls Specify): _____________
⟤ Ethnic Affiliation (Pls Specify): _____________
Name of Legal Counsel/s (Abogado): Email address:
RESPONDENT INFORMATION(Impormasyon ng nirereklamo)
Last name (Apelyido): Middle name (Gitnang Pangalan):
First name (Unang Pangalan): Alias (Alyas):
Date of Birth (Kapanganakan): Age(Edad): Corporation or Company being represented:
Sex: Citizenship:
⟤Male/Lalaki ⟤Female/Babae If foreigner indicate Passport or ACR. No.:
______
Civil Status Occupation:
⟤ Married ⟤ Single ⟤ Private ⟤ Government
⟤ Others (Pls Specify): ______________ ⟤ Others (Pls Specify): ______________
Present Address: Permanent Address:
Telephone/Mobile Number: E-mail Address:
Other Information:
⟤ Person with Disability Religion: ______________
⟤ Senior Citizen Other (Pls Specify): _____________
⟤ Ethnic Affiliation (Pls Specify): _____________
Offense (Krimen): Counts (Bilang ng kaso):
Date and time (Petsa at oras ng pangyayari): Place (Lugar ng Pangyayari):
WITNESSES(Saksi):
Last name (Apelyido): Middle name (Gitnang Pangalan):
First name (Unang Pangalan): Address (Tirahan):
Documents and Evidences Submitted:
__________________________________ _______________________________
__________________________________ _______________________________
__________________________________ _______________________________
__________________________________ _______________________________
__________________________________ _______________________________
__________________________________ _______________________________
1. Has similar complaint been filed before any other office? *⟤ Yes ⟤ No
2. Is this complaint in the nature of a counter-charge? *⟤ Yes ⟤ No
If yes, indicate details.
3. Is this complaint related to another case filed before this Office? * ⟤ Yes ⟤ No
If yes, indicate details.
CERTIFICATION*
I CERTIFY, under oath, that all information in 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 if I should thereafter learn that similar action has been filed and/or pending, I
shall report that fact to this Honorable Office within five (5) days from knowledge
thereof.
________________________________
(Signature over printed name)
⟤Complaint/⟤Counsel/⟤Law Enforcer
SUBSCRIBE AND SWORN TO before me this ____ day of _____________,______
in the City of _________________.
________________________________
(Prosecutor Administering Oath)
*1,2,3 Certification need not be accomplished for Inquest cases
