Republic of the Philippines

Department of Justice
NATIONAL PROSECUTION SERVICE
OFFICE OF THE CITY PROSECUTOR
PASAY CITY
INVESTIGATION DATA FORM

To be accomplished by the Office:

DATE RECEIVED: NPS DOCKET NO.:

(stamped and initiated): ___________

XV-14-INV-14H-
Time Received: ___________ Assigned to: ______________________
Receiving Staff: ___________ Date Assigned:____________________

To be accomplished by complainant/cousel/law enforcer:

(Use back portion if space is not sufficient)

COMPLAINANT/s: Name, Sex, Age & Address
ADRIENNE ESPAÑOLA y CATAGUE,
female, 22 years old (DOB 03-08-1997) and
presently residing at Unit 201 Evalber Residential
Building, Mabolo Street, Pasay City.
RESPONDENT/s: Name, Sex, Age & Address
MICHAEL KEAN L. CAI, male, 27 years
and a resident of No. 2166-2168 Dr. M. Carreon
Street, Sta. Ana Manila.

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

Art. 266-A of RPC

DATE & TIME of COMMISSION: PLACE of COMMISSION:

On or about 10:30 PM of April 25, 2019 At Mustang Security System, Inc.
Compound, Msai Building, 89 Liman Street,
Barangay 3, Pasay City.

1. Has a 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 below
3. Is this complaint related to another case before this office? YES__ NO__ If yes, indicate 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 filed any claim involving the same issues
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____, in __________
_____________.

________________________________
(Signature over printed name)

*1, 2, 3 and CERTIFICATION need not be accomplished for inquest cases