Republic of the Philippines

Department of Justice
National Prosecution Service
OFFICE OF THE PROVINCIAL PROSECUTOR
San Fernando City, La Union

To be accomplished by the Office

DATE RECEIVED DOCKET NUMBER

Time Received
Receiving Staff ASSIGNED TO
(Stamped and initialed) DATE ASSIGNED

To be accomplished by the complainant/counsel/law enforcer (use back portion or additional forms, if necessary)

COMPLAINANT INFORMATION (Impormasyon ng Nagrereklamo)

Last Name (Apelyido): Middle Name (Gitnang Pangalan):
FLORES GURON
First Name (Unang Pangalan): Alias (Alyas):
LOURDES
Date of Birth (Kapanangakan): Age (Edad): Corporation or Company being represented:
OCTOBER 1, 1954 64
Sex(Kasarian): Citizenship (Pagkamamayan):
Male/Lalake X Female/Babae If foreigner indicate Passport or ACR No.:__________
Civil Status: Occupation (Trabaho):
X Married Single X private government

Others (Pls. Specify): Others (Pls. Specify):

Profession(propesyon):

Present Address: (Kasalukuyang Tirahan) Permananent Address(Permanenting Tirahan):

TANQUIGAN, SAN FERNANDO CITY, LA UNION
Telephone/Mobile Number (telepono) E-mail Address:

Other Information: Religion/Relihiyon:

Person with Disability/May Kapansanan Others (Pls. Specify):
X Senior Citizen/Nakakatandang Mamamayan
Ethnic Affiliation/Tribo (Pls. Specify):
Name of Legal Counsel/s(Abogado) Email Address:

RESPONDENT INFORMATION (Impormasyon ng Nirereklamo)

Last Name (Apelyido): Middle Name (Gitnang Pangalan)

1. FLORES 1. AJOLO
2. GURON 2. FLORES
First Name (Unang pangalan) Alias (Alyas)
1. RICARDO
2. VIOLETA
Date of Birth (Kapananganakan) Age(Edad) Corporation or Company being represented:
Of legal ages
Sex (Kasarian): Citizenship (Pagkamamayan):
x Male/Lalaki x Female/Babae If foreigner indicate Passport or ACR No.:__________
Civil Status: Occupation (Trabaho):
Married Single private government
Others (Pls. Specify): Others (Pls. Specify):
Profession (Propesyon):
Present Address (Kasalukuyang Tirahan): Permanent Address (Permanenteng Tirahan):
Tanquigan, San Fernando City, La Union
Telephone/Mobile Number (telepono): E-mail Address:

Other Information: Religion/Relihiyon:

Person with Disability/May Kapansanan Others (Pls. Specify):
x Senior Citizen/Nakakatandang Mamamayan
Ethnic Affiliation/Tribo (Pls. Specify):
Offense (Krimen): Counts:

Date and Time (Petsa oras ng pangyayari): Place (Lugar ng pinangyarihan):

WITNESSES (Saksi)
Last Name (Apelyido): reservation for several Middle Name (Gitnang pangalan):
witnesses

First Name (Unang pangalan): Address (Tirahan):

Documents and Evidence Submitted:

1. Has a similar complaint been filed before any other office?* Yes x No
2. Is this complaint in the nature of a counter-charge?* Yes x No
If yes, indicate details.
3. Is this complaint related to another case filed before this Office?* Yes x No
If yes, indicate details.

C E R T I F I C A T I O N*

I CERTIFY, under oath, that all information in 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 judicial agency and if I should thereafter learn that a similar action has been filed and/
or pending, I shall report to this Honorable Office within five (5) days from knowledge thereof.

LOURDES F. FLORES
(Signature over printed name)
Complainant/ Counsel/ Law Enforcer

SUBSRIBED AND SWORN TO before me this day of February, 2019

of San Fernando City, La Union.

(Prosecutor Administering Officer)

*1,2,3 & Certification need not be accomplished for Inquest cases

Revised Manual for Prosecutor Volume 3 2017 Edition