Republic of the Philippines

NATIONAL POLICE COMMISSION

PHILIPPINE NATIONAL POLICE
TARLAC POLICE PROVINCIAL OFFICE
PANIQUI MUNICIPAL POLICE STATION
Brgy. Poblacion Norte, Paniqui, Tarlac

PPS-IN March 4, 2019

CERTIFICATION
(Excerpt from the Police Blotter)

TO WHOM IT MAY CONCERN:

THIS IS TO CERTIFY that as per record kept/filed in the Police Blotter entry no.
2019-9378 of this station, dated March 4, 2019, the following data exist to wit:

“ At about 2:00PM of March 4, 2019 One (1) Herbert Roldan Donato y

Ramilo, 41 years old, married, resident of Brgy. Estacion, Paniqui, Tarlac
appeared before this office and presented a copy of Affidavit of loss issued by
Atty. David P Briones dated March 4, 2019 with Doc. No. 221, page no. 19 series of
2019 and as averred by the reportee at about 3:00PM of February 28, 2019 while
he was on board of a Motorized tricycle and when he got home he notice that his
wallet containing of his Professional driver’s license was missing believed to be
dropped/fall at the said tricycle and believed it lost beyond recovery SIGNED:
HERBERT ROLDAN R DONATO.

This certification is being issued upon verbal request for whatever legal intent it
may serve.

FOR THE CHIEF OF POLICE:

Prepared By:

Edgar G Reyes
Police Senior Master Sergeant
Investigator
HCUI CASES
rd
and 3
Quarter 2016
Cases 8
Focus Crime
 TABLE OF CONTENTS
SPOT REPORT----------------------------------------------------------- A

FINAL PROGRESS REPORT---------------------------------------- B

PROGRESS REPORT-------------------------------------------------- C

AFFIDAVIT OF COMPLAINANT/WITNESS---------------------- D

AFFIDAVIT OF ARREST---------------------------------------------- E

INVESTIGATIVE DATA FORM/INFORMATION/RESOLUTION---

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DEATH CERTIFICATE/
MEDICAL CERTIFICATE--------------------------------------------- H

INCIDENT RECORD FORM------------------------------------------ I

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