NPS Investigation Form No. 01 s.

2008

Republic of the Philippines

Department of Justice
NATIONAL PROSECUTION SERVICE, REGION III
Office of the City of Prosecutor
City of San Jose del Monte, Bulacan

INVESTIGATION DATA FORM

To be accomplished by the Office:
DATE RECEIVED: NPS DOCKET NO.:
(stamped and initiated):
Time Received: Assigned to:
Receiving Staff: Date Assigned:

To be accomplished by complainant/counsel/law enforcer

(Use back portion if space is not sufficient)

COMPLAINANT/s: Name, Sex. Age & Address RESPONDENT/s: Name, Sex, Age & Address
1. ROSALYN PEREZ-SARMIENTO, Female, 44 y/o 1. SERGIO SARMIENTO y RAYO, Male
Blk 41 Lot 25 Area I, Brgy. Lawang Pare Blk 41 Lot 25 Area I, Brgy. Lawang Pare
City of San Jose del Monte, Bulacan City of San Jose del Monte, Bulacan

2 MINDA PASCUAL, Female

Minuyan-Norzagaray

OFFENSE/s COMMITTED / LAW/s VIOLATED:

1. Violence against Women and their Children Act of
R.A. 9262, Concubinage and Adultery

WITNESS: NAME, SEX, AGE & ADDRESS:

DATE & TIME of COMMISSION: PLACE of COMMISSION:

2011; April 7, 2017 San Jose del Monte; Norzagaray, Bulacan

1. Has a similar complaint been filled before any other office?* YES NO x
2. Is this complaint in the nature of a counter-charge?* 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
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.

ROSALYN PEREZ-SARMIENTO

SUBSCRIBED AND SWORN TO before me this __day of _______________ here City of San Jose del
Monte, Bulacan.

Administering Officer
Administering Prosecutor / Officer