REPUBLIC OF THE PHILIPPINES DEPARTMENT OF JUSTICE Quezon City INVESTIGATION DATA FORM To be accomplished by the Office DATE RECEIVED NPS DOCKET No.: (stamped and initiated): Time Received: Assigned to: Received Staff. Date Assigned: To be accomplished by complainants/counsel/law enforcer (Use back portion if space is not sufficient) COMPLAINANT/S: Name. Sex, Age, & RESPONDENT/S: Name, Sex, Age & Address Address OFFENSE/s COMMITTED/LAW/s WITNESS/es: Name & Address VIOLATED: DATE & TIME of COMMISION: PLACE of COMMISION: 1. Has a similar complaint been filed before any other Office?" YES__NO_x_ 2. Is this complaint in the nature of a counter-affidavit?* YES_ NO_X_ If yes, indicate details below. 3. Is this complaint related to another case before this office?" YES_NO_x_ 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) (Signature over printed name SUBCRIBED AND SWORN TO before me this Administering Prosecutor/Officer