Professional Documents
Culture Documents
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
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:
Anoangdahilbakitkanaritosaamingtanggapan?
05 Tanong:
Sino namanangiyonginirereklamo?
Sagot:
06 Tanong:
Sagot:
Dahilpinagpapalopoakongbato.
07 Tanong:
Kailan at saannangyariangsinasabimongpagpalongbatosaiyo?
Sagot:
08 Tanong:
Sagot:
09 Tanong:
Ano pa angsumunodnanangyari?
Sagot:
Binuhatnapoakongmgakaibiganko at
dinalaakosaBaranggaydahilnandoonpoyungambulansya at dinalaakosa
San Lorenzo Hospital.
10 Tanong:
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
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:
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
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.
OFFICERS ON CASE:
PO1 JESSE DE LEON CORNEL and PO1 MELISSA A. GOHING
WCPD, Quezon City Police Station, Quezon City
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
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
SUBJECT
DATE
December 8, 2013
(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
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:
.
(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
FORM NO. 27
ACTS OF LASCIVIOUSNESS
COMPLAINANT
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