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FORM NO.

16
EXAMPLE OF POLICE REPORT FORMAT
Republic of the Philippines
National Police Commission
Philippine National Police
Quezon City Police Station
City of Quezon, Metro Manila
MCT5-IN

March 30, 2009


CERTIFICATION

TO WHOM IT MAY CONCERN:


THIS IS TO CERTIFY that based on the Police Blotter of the station, as shown on
page 10, under Entry No. M-2008-061, dated March 30, 2009, the following entries of
events exists to wit;
March 30, 2009/1502H/C2008-061
SLIGHT PHYSICAL INJURY
Stated in this portion is the statement of facts that answer the 5Ws and 1 H
pertaining to the incident.
The reporter has affixed his signature this 30 th day of March 2009.
SGD. MICHAEL E. CHAN
(Reporter)
This certificate is issued upon the request of Mr. Nell V. Reyes for whatever legal
purposes and interest it may serve.
Prepared by:
FRANCIS A. FUENTE
PO3
PNP
Officer on- Case
Noted by:
MIGUEL A. VELASCO
Police Superintendent
Chief of police

FORM NO. 17
SAMPLE SINUMPAANG SALAYSAY
Kusangloobnasalaysayni PATRICK JAN VILLAREY y DIOSIO naibinigaykay PO1
JESSE DE LEON CORNEL ng Women and Child Protection Desk, Quezon City Police
Station ngayongika 02 ngAbril 2009 saganapnaika- 8:30
ngumagasaharapngkanyangnanay ma si WIL MAY VILLAREY.
01 Tanong:

Gng.
PATRICK
JAN
VILLAREY
ay
kukuhanankongsalaysayhinggilsakanyangreklamosakanyangpangbubugb
og,
ngunitsakadahilaanannasiyaisangmenor
de
edad
at
sailalimngatingBagongSaligang Batas siya ay nangangailangan pa
ngiyongpahintulot at patnubayupangmakapagbigayngisang MALAYANG
SALAYSAY, ikawba ay pumapayagnasiya ay kunanngsalaysay at
iyonggagabayansaimbestigasyongito?

Sagot:

OPO.

02 Tanong:

PATRICK
JAN
VILLAREY,
ikawba
nakahandangmagsabingkatotohanansapagsisiyasatnaito?

ay

Sagot: OPO.

03 Tanong:

Sagot:

04 Tanong:

Sabihinmongmulisa akin angiyongbuongpangalan?

Akoposi PATRICK JAN VILLAREY y DIOSIO, 11 taonggulang (January 2,


1998), estudyante at nakatirasa No. 108 Purok 3, Maligaya, Quezon City.

Anoangdahilbakitkanaritosaamingtanggapan?

Sagot: Para pomagreklamo.

05 Tanong:

Sino namanangiyonginirereklamo?

Sagot:

Sila BALTAZAR DE VEGA y BARRIO, 33 taonggulang, may asawa,


Jeepney driver at kasalukuyangnakatirasa No.6 Sampaguita,
BagongLipaan, Maligaya, Quezon City at si CRISOSTOMO ANTONIO y
MASLOG, 24 taonggulang, binata at sidewalk vendor at nakatirasa No.6
Sampaguita, BagongLipaan, Maligaya, Quezon City.

06 Tanong:

Bakitmoinirereklamosila BALTAZAR DE VEGA y BARRIO at


CRISOSTOMO ANTONIO y MASLOG?

Sagot:

Dahilpinagpapalopoakongbato.

07 Tanong:

Kailan at saannangyariangsinasabimongpagpalongbatosaiyo?

Sagot:

08 Tanong:

Sagot:

09 Tanong:

Kagabipohumigitkumulang alas 9:30 nggabipetsangAbril 01,


2009saBagongLipaan, Maligaya, Quezon City.

Maaarimo bangisalaysaysa akin angbuongpangyayari?

Kagabiponapadaan kami ngmgakaibigankosaMang Juan Restaurant,


pauwinapo kami galingsaperyahanpagdaannaminsaBagongLipaan ay
napagkamalan kami angbumatosakanila kaya hinabol kami kung kaya
nagtakbuhan kami, at mganakainomposila.
Nahuliakongtumakbobiglangbiglaakonghinawakannungisanglalakinanakaputing T-shirt nasi CRISOSTOMO. Pinagsusuntokakosaakinglikod at
kumuhayungnaka-green nasandonasi BALTAZAR ngbato at
ipinalosaakinglikod, saulo, pinalongkaibigankosi BALTAZAR kaya
binitawanakoperopinagsusuntok pa nilaakosaakingkatawan at
saakingnguso.

Ano pa angsumunodnanangyari?

Sagot:

Binuhatnapoakongmgakaibiganko at
dinalaakosaBaranggaydahilnandoonpoyungambulansya at dinalaakosa
San Lorenzo Hospital.

10 Tanong:

Pansamantalawalanamunaakongitatanongsaiyo may sasabihinka pa ba?

Sagot:

Walanapo.

11 Tanong:

Handabaitonglagdaanbilangpatunaysaiyongsinasabi?

Sagot: OPO.

(sgd)
PATRICK JAN VILLAREY y DIOSIO
Nagsalaysay

Witnesses:Arlho A. Bautista

I hereby certify that I have personally examined the affiant /s and that I am
satisfied that he/she/they voluntarily executed and understood his/her/their affidavit.

(Sgd)
FRANCIS B. TORRES
ASSISTANT CITY PROSECUTOR

FORM NO. 18
SAMPLE PINAGSAMANG SALAYSAY
RepublikangPilipinas )
LungsodngQuezon )

S.S

PINAGSAMASAMANG MALAYANG SINUMPAANG SALAYSAY

Kami sina MARCOS FRANCO y RILAY, 15 taonggulang (May 14, 1994), OSY at
nakatirasa Valencia St.,Purok 3, Maligaya, Quezon City at FERDINAND PEDRO y
BRAGANTE, 15 taonggulang (June 5, 1994) OSY at nakatirasaPurok 3, Block 1, Guena
St., Maligaya, Quezon City,napinatnubayniGng. Rosalina R. Benidesng SSD,
Lungsodng Quezon at sailalimngatingBagongSaligang Batas naumiiralsakasalukuyan
ay buonglayangnagsasabingmgasumusunod:

NA, Kami po ay pawing menor de


edadnatumatayongtestigosakasongisinumpani PATRICK JAN VILLAREY
sakasongpamumukpoksaulo at mukhalabankay BALTAZAR DE VEGA y BARRIO at
CRISOSTOMO ANTONIO y MASLOG.

NA, humigitkumulang 9:30 nggabipetsangAbril 01, 2009, kami, kasamasi


PATRICK JAN VLLAREY at iba pa naming kaibigan ay
naglalakadnapauwisaaminnangmapadaan kami saBagongLipaanhabangnaglalakad ay
nakita naming na may ilangbatoangtumatamasaamin at nagsisigawanangibangtaodoon.
Napahintopo kami at napadaansaaminangdalawanglalakinasina BALTAZAR at
CRISOSTOMO nangbiglanghilahinsi PATRICK JAN papuntasamadilimni
CRISOSTOMO at angkasamaniyangsi BALTAZAR. May
sinagpongkontingliwanagangpinagdalhansakanya, kung kaya nangpukpukinsiyasaulo at
mukhani CRISOSTOMO habanghawaksiyani BALTAZAR ay nakitapo naming iyon.

NA, hindinamanponaminmapuntahansi PATRICK JAN


habangpinagpapalosyangdalwanglalakidahil may nambabato din
posaamingalingsaaminglikuran kaya nangiwanansiyanila BALTAZAR at CRISOSTOMO
ay agad naming syangpinuntahan. Nang makitanainsya ay duguannasya at hilong-hilo

at hindiposiyamakatayongmaayos at doonnaposiyanawalanngmalay.
HanggangsaitakbonaposiyasaOspital. Habang kami ay nagpuntasa Barangay
ngMaligaya.
NA, habang kami ay nandonsa Barangay Maligaya ay dumatingangilangmga
barangay Pulisdalaangdalawanglalaki. Nang mamukhaan naming sila aypositibo
naming itinuronasilaangnagdalasamadilimnalugar at pumalosaulo at samukhani
PATRICK JAN nanagingdahilanpoparamawalansiyangmalay.

NA, lahatpongamingisinalaysay ay pawing katotohananlamangnawalangsinumang nagutos o namilitupangito ay aminggawin at bilangpatotoo ay aminginilagdaan n gaming
pirmasailalimngkasulatangito.

(SGD)
FERDINAND PEDRO y BRAGANTE
Nagsalaysay

(SGD)
MARCOS FRANCO y RILAY
Nagsalaysay

Pinatnubayanni:
(SGD)
Gng. ROSALINA R. BENIDES
SSD Representative
SUBSCRIBED AND SWORN TO BEFORE ME THIS DAY OF OCTOBER 3, 2015 AT
CITY OF QUEZON, PHILIPPINES
CERTIFICATION
I hereby certify that I have personally examined the affiant /s and that I am satisfied that
he/she/they voluntarily executed and understood his/her/their affidavit.

(Sgd)
FRANCIS B. TORRES

ASSISTANT CITY PROSECUTOR


FORM NO. 19
SAMPLE OF INQUEST
Republic of the Philippines
NATIONAL POLICE DISTRICT
NOTHERN POLICE DISTRICT
QUEZON City police station
Women and Children Protection Desk
City of Quezon
MEMORANDUM
FOR

IS No. 08-K 05338


: The Honorable City Prosecutor
City Prosecutors Office
Quezon City

SUBJECT

: INQUEST
Re: Frustrated Homicide
In relation to Violation of RA 7610 (Child Abuse)

DATE

: 02 April 2009

RESPECTFULLY REFERRED for inquest to the City prosecutors office the living
person of BALTAZAR DE VEGA y BARRIO and CRISOSTOMO ANTONIO y MASLOG
including pertinent documents relative to as case of Frustrated Homicide in relation to
violation of RA 7610 (child abuse) committed at about 9:30 p.m of 01 April 2009 at
BagongLipaan, Maligaya, Quezon City lodge by herein complainant, requesting for
evaluation and proper disposition to wit:
COMPLAINANT / VICTIM:
PATRICK JAN VILLAREY y DIOSO, 11 YRS. OLD BORN on January 02, 1998, student
and a resident of No. 108 Purok 3, Maligaya, Quezon City (Assisted by his mother,
MRS. WIL MAY VILLAREY)
SUSPECTS (Arrested):
BALTAZAR DE VEGA y BARRIO, 33 Yrs. Old, Married, Jeepney driver and a resident of
Sampaguita #6, BagongLipaan, Maligaya, Quezon City.

CRISOSTOMO ANTONIO y MASLOG, 24 Yrs. Old, Single, Construction worker ang a


resident of Sampaguita #6, BagongLipaan, Maligaya, Quezon City.
ARRESTING OFFICERS:

B/P ENRIQUE ESPEJO AND B/P PETER VUENTE


Brgy. Police of Brgy, Barangay, Quezon City

OFFICERS ON CASE:
PO1 JESSE DE LEON CORNEL and PO1 MELISSA A. GOHING
WCPD, Quezon City Police Station, Quezon City

FOR THE CHIEF OF POLICE

RICA MARIE DALIW


Police Chief Inspector
Chief, WCPD

Incls;
SS of minor victim
Affidavit of Arrest
Waiver of Detention
Medical Certificate of Victim issued by San Lorenzo Hospital
Medico-legal exam result to follow
Birth Certificate of minor victim to follow

FORM NO. 2O
SAMPLE NATIONAL PROSECUTORS SERVICE
Republic of the Philippines
Department of Justice
NATIONAL PROSECUTION SERVICE
OFFICE OF THE CITY PROSECUTOR
Quezon City
I.S.N.O. 08 K 05338
PATRICK JAN VILLAREY y DIOSIO
Assisted by his mother, WIL MAY VILLAREY
-ComplainantFOR: Frustrated Homicide in
Ref. to viol.of RA 7610
(Child Abuse)
-versusBALTAZAR DE VEGA y BARRIO
CRISOSTOMO ANTONIO y MASLOG
-RespondentREQUEST FOR PRELIMINARY INVESTIFATION AND WAIVER OF ARTICLE 125
REVISED PENAL CODE.
I wish my waived of right to Preliminary Investigation and for this purpose. I
hereby voluntarily waive my right under the provision of Art.125 of the revised penal
Code pending the completion of the Preliminary Investigation Proceeding. I agree to
remain under the Police Custody.
Quezon City, Philippines
(Sgd)
BALTAZAR DE VEGA y BARRIO
CRISOSTOMO ANTONIO y MASLOG
Respondent
(Signature over printed name)
Assisted By:
Responsible Person/ Counsel

FORM NO. 21
SAMPLE REGIONAL TRIAL COURT INFORMATION
Republic of the Philippines
REGIONAL TRIAL COURT
NATIONAL CAPITAL JUDICIAL REGION
CALOOCAN CITY
PEOPLE OF THE PHILIPPINES
CRIM CASE NO. 123-244
(I.S 4044k-7456)
Versus
-for-

Murder
IN RELATION TO RA 1234

Nathanielle sistemio and Kenneth decano


(BOTH of Hillcrest Village camarin blk 14 lot 24, Caloocan city) and
ACCUSED: N/A
Detained: Caloocan city Jail
X- - - - - - - - - - - - - - - - - - - X
I N F O R MATI O N

The undersigned Assistant City Prosecutor accuses Nathanile sistemmio and


Andres Bonifacio of the crime of Frustrated Homicide in relation to RA 210, committed
as flows:

That on or about the 14st day of April, 2014 in the City of Caloocan, Philippines, and
written the jurisdiction of the Honorable Court, the above-named accused, conspiring,
confederating, and mutually helping and aiding one another, armed with stone, with
intent to kill, did then and there willfully, unlawfully and feloniously attack, assault, strike
a stone, Lorenzo Cayabyab, 55 year old minor, in the different parts of the body and
head, continuously punching and hitting his mouth and body, thereby inflicting upon his
person wounds which are fatal, thus performing all the acts his person wounds which
should have produced the crime of homicide, as a consequence but nevertheless did
not produce it by means of a cause independent of his will, that is due to the timely and
able medical attendance rendered which prevented his death, such acts of child abuse
are prejudicial to the development and growth of Lorenzo Cayabyab

Contrary to law,
Caloocan city , December 8, 2009

John Dalton
Assistant City Prosecutor

I hereby certify that the foregoing information is filed pursuant to Section 6, Rule
1444 of the Rules on Criminal Procedure, as amended, the accused not having opted to
avail of his right to a preliminary investigation and not having executed a waiver
pursuant to Article 123 of Revised Penal Code, I further certify that the information is
being filed with the prior authority of the City prosecutor having been first obtained.
Nyora Aguda
Assistant City Prosecutor

SUBSCRIBE AND SWORN to before me this 13th day of December 8 , 2019 Caloocan
City

Arnold B. Lapada
Assistant City Prosecutor

FORM NO. 22
SAMPLE REQUEST FOR MEDICO LEGAL EXAM
HEADQUARTERS
QUEZON CITY POLICE STATION

CRIMINAL INVESTIGATION SECTION


City of Quezon
MEMORANDUM
FOR

The Health Officer


San Lorenzo Hospital
SAN LORENZO, Caloocan city

SUBJECT

MEDICO Legal Examination Request for

DATE

December 8, 2013

1. Respectfully request to conduct medico legal examination the living person of


BALTAZAR DE VEGA y BARRIO, 26 Yrs. Old, Married, Taxi driver and a resident
of San Lorenzo Blk 12 Lot 2 Hillcrest village Caloocan city.
2. Subject person is a suspect of alleged Child Abuse that took place at
BagongLipaan, Maligaya, Quezon City on or about 9:30 pm of September 2,
2013 Likewise said suspect is a complainant of alleged physical injury that
occurred at front of Prosecutors building around 8:00 pm August 4, 2011
3. Hoping for your usual cooperation regarding this matter.

(Sgd)
BAUTISTA ARLHO S.
Police Senior Inspector
Chief, Investigation
FORM NO. 23
JURAT

SUBSCRIBED AND SWORN to before me, this day of December 8,2012 by, who
exhibited to me his community Tax No 53253 issued at TCP on September 9.2001

Notary Public
Until January 1, 2015
PTR NO.35223 (June 4, 2014 Caloocan Municipality)
Roll of Atty. No44-122-2341
IBP Receipt No 04-212-2341 (August 22, 2013 Caloocan City Municipality)
Doc. No 333
Page No2312
Book No 23331
Series of 2014

This is a certification by an officer authorized to administer oath, that the truth of the
statement was affirmed before him by the affiant. If the affiant is not known to the officer
or notary public competent evidence of identity is necessary.

FORM NO. 24
AFFIDAVIT OF LOSS OF DRVERS LICENSE

REPUBLIC OF THE PHLIPPINES )


MUNICIPAL OF CALOOCAN CITY )
PROVINCE OF MANILA )

SS

AFFIDAVIT
I Arlho Bautista of legal age, single/married Yannah Datu
And a
Resident of Caloocan city after having been duly sworn on oath in accordance with the
law hereby voluntarily depose and say:
1. That I am a driver with profession, with License No. 2135512
Issued by the Board of transportation at Caloocan city.
2. That sometimes between the months of July and March I was at Caloocan
city and thereat earning my livelihood as driver for Mrs. valuenzuela
3. That quite by accident, on the Day of November more or less, my wallet fell
from my hip pocket while I was on my way to work; That I noted the loss only when,
upon reaching my destination, I saw that my wallet was gone, together with my drivers
License No.. and a little money.
4. That I took pains to look for said wallet and license but to no avail.
5. That I am executing this statement to attest to all the above facts, and to request the
proper authorities to grant me a new license.
IN TRUTH WHEREOF, I have hereunto signed my name below, thisday of
December 8, 2000 at Caloocan City
Jason C. Avalos
Affiant

FORM NO. 25
SPECIAL POWEROF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS:

We Residence and , spouses, of legal age. With residence and pot-office


address at Quezon Avenue
Do hereby APPOINT, NAME and CONSTITUTE..., likewise
Of legal age, single/married to with residence at.
As our true and legal representative to act for and in our name and stead and to perform
the following acts during the period of time that we shall be abroad;
To sell, offer for sale, and come to an agreement as to the purchases price and
thereafter to sign for us and in our name and receive the consideration for the sale of
our share in the following described realities:
(Description)
HEREBY GRANTING unto our representative full power and authority to execute
and perform every act necessary to render effective the power to sell the foregoing
properties, as though we ourselves, have so performed it, and HEREBY APPROVING
ALL that he may do by virtue hereof with full night of substitution of his person and
revocation of this instrument.
IN WITNESS WHEREOF
, WE HAVE HEREUNTO SET OUR HANDS
THIS. DAY OF.. 200_________.

WITNESSES: Michael E. Chan

.
(ACKNOWLEDGEMENT WHERE THE PRINCIPAL IS NOT
PERSONALLY KNOWN TO THE NOTARY PUBLIC BUT PRESENTS COMPETENY
EVIDENCE OF IDENTITY)

FORM NO. 26
FORM OF COMPLAINANT IN CRIMINAL CASES

Violation of Municipal ordinance #255


COMPLAINANT
THE UNDERSIGNED
.. accuses
of the violation of Ordinance No.
Series of 2000.., of the municipality of. Committed as
Follows:
That on or about the day of. 2000., in the
Municipality of . And within the jurisdiction of this
Hon. Court, the said accused did then and there willfully and unlawfully caused the
unloading and storage of two hundred (200) cans of kerosene gas in his store bodega
situated at .. Street, Municipality of, against the
Specific prohibition of Ordinance No.. of the Municipality, which authorizes only the
storage of gas up to not more than ten (10) cans, for reasons of fire prevention and
public safety.
Municipality of Caloocan city
Date: December 8, 2015
Arlho S. Bautista
.
Chief of Police
WITNESSES:Arlho A. Bautista
Name Vincent Portillo
camarin Caloocan city

Address: Hillcrest Village

FORM NO. 27

ACTS OF LASCIVIOUSNESS

COMPLAINANT

The undersigned accusesOf the crime of


ACTS OF LASCIVIOUSNESS defined and penalized under Art. 336 of the Revised
Penal Code, committed as follows:

That on or about the ..day of....2000.., in the


Municipality of. Province of, and within the
Jurisdiction of this Hon. Court, the said accused. Did then
And there willfully, unlawfully, and feloniously embrace on Elha de Jesus, when the
latter was about to enter a public latrine, holding breasts and taking liberties upon her
person by force and against the will of said Elha de Jesus.

Contrary to law:
R.A 1444
.,2010
Andrew Collins
.
Offended party
Note:
The elements of the crime are: (1) Any act of lasciviousness or lewdness, (2) the same
is committed under any of the following circumstances

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