Republic of the Philippines

Department of Justice
NATIONAL PROSECUTION SERVICE
OFFICE OF THE PROSECUTOR
MANILA CITY

INVESTIGATION DATA FORM

To be accomplished by the Office:

NPS DOCKET NO.:

DATE RECEIVED:

(Stamped and Initialed) ___________________

Time Received: ________________________
Receiving Staff: ________________________

XV-07-INV

Assigned to: __________________________

Date Assigned: _______________________

To be accomplished by complainant/ counsel/ law enforcer:

(Use back portion if space is not sufficient)
COMPLAINANT/s: Name, Sex, Age & Address
____________________________________

RESPONDENT/s: Name, Sex, Age & Address

_____________________________________

_RAMON G. TALAN___________________

RONALD C. PEREZ_____________________

_____________________________________

_____________________________________

____________________________________

_____________________________________

OFFENSE/s COMMITTED/ LAW/s VIOLATED:

WITNESS/es: Name& Address

_____________________________________

_JOSELITO P. VILLA- at No. 592 J.P.

Rizal __PERJURY under Art. 183______________

Street, Brgy.

Concepcion, Marikina City

__of the Revised Penal Code_____________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

_____________________________________

DATE & TIME OF COMMISSION:

PLACE OF COMMISSION:

______March 7, 2016___________________

____Quezon City______________________

_____________________________________

_____________________________________

1. Has a similar complaint been filed before any other office?*

2. Is this complaint in the nature of a counter- charge?*
3. Is this complaint related to another case before this office?*
4.

YES____
YES____
YES____

NO____
NO____ If yes, indicate details below
NO____ if yes, indicate details below

I.S./NPS Docket No. __________________________

Handling Prosecutor:__________________________

C E R T I F I C A T I O N*
I CERTIFY, under oath, that all the information in this sheet is true and correct to the best of my
knowledge and belief, I have not commenced any action r filed any claim involving the same issues in
any court, tribunal, quasi-judicial agency, and that if I should learn that a similar action has been filed
and/or is pending, I shall report that fact to this Honorable Court within five (5) days from knowledge
thereof.
________________________________________
(Signature over Printed Name)
SUBSCRIBED AND SWORN TO before me this ____________ day of ____________, 20___,
in _________________________________________.

Administering Prosecutor/ Officer