Republic of the Philippines

Department of Justice
National Prosecution Service
Region XII

Office of the City Prosecutor

City of Tacurong

INVESTIGATION DATA FORM

To be accomplished by the Office
DATE RECEIVED: _________________________________ DOCKET NUMBER
XII-03-IN___ -_____ - _________________
Time Received: __________________________________
ASSIGNED TO: __________________________________
Receiving Staff: __________________________________
(Stamped and initialed) DATE ASSIGNED: ________________________________
To be accomplished by the complainant/counsel/law enforcer (Use additional forms if necessary)

COMPLAINANT INFORMATION (Impormasyon ng Nagrereklamo)

Last Name(Apelyedo): Middle Name (Gitnang Pangalan):
GRECIA DEL OESTE
First Name (Unang Pangalan): Alias (Alyas):
ERWIN
Date of Birth (Kapanganakan): Age Corporation or Company being represented:
(Edad):
Legal age
Sex (Kasarian): Citizenship (Pagkamamamayan): Filipino
If foreigner indicate Passport or ACR NO. : ____________
Male (Lalaki) Female (Babae)
Civil Status: Occupation (Trabaho):
Private Government
Married ✔️ Single Others (Pls. Specify): _________________
Others (Pls. Specify): _________________ Profession (Propesyon):_________________

Present Address (Kasalukuyang Tirahan): Permanent Address (Permanenteng Tirahan):

Purok 2, Barangay Rajah Muda, Tacurong City Purok 2, Barangay Rajah Muda, Tacurong City

Telephone/Mobile Number (Telepono): E-mail Address:

Other Information: If a member of Law Enforcement Agency:

Person with Disability/May Kapansanan Position:__________________________
Senior Citizen/Nakakatandang Mamamayan Name of Agency:___________________
Ethnic Affiliation/Tribo (Pls. Specify): ________________

COMPLAINANT INFORMATION (Impormasyon ng Nagrereklamo)

Last Name(Apelyedo): Middle Name (Gitnang Pangalan):
GRECIA
First Name (Unang Pangalan): Alias (Alyas):
RONALYN
Date of Birth (Kapanganakan): Age Corporation or Company being represented:
(Edad):
Legal age
Sex (Kasarian): Citizenship (Pagkamamamayan): Filipino
If foreigner indicate Passport or ACR NO. : ____________
Male (Lalaki) ✔️Female (Babae)
Civil Status: Occupation (Trabaho):
Private Government
Married ✔️ Single Others (Pls. Specify): _________________
Others (Pls. Specify): _________________ Profession (Propesyon):_________________

Present Address (Kasalukuyang Tirahan): Permanent Address (Permanenteng Tirahan):

Purok 2, Barangay Rajah Muda, Tacurong City Purok 2, Barangay Rajah Muda, Tacurong City

Telephone/Mobile Number (Telepono): E-mail Address:

Other Information: If a member of Law Enforcement Agency:

Person with Disability/May Kapansanan Position:__________________________
 Senior Citizen/Nakakatandang Mamamayan Name of Agency:___________________
Ethnic Affiliation/Tribo (Pls. Specify): ________________

RESPONDENT INFORMATION (Impormasyon ng Nirereklamo)

Last Name(Apelyedo): Middle Name (Gitnang Pangalan):
RAMOS DEL OESTE
First Name (Unang Pangalan): Alias (Alyas):
SUSANA
Date of Birth (Kapanganakan): Age Corporation or Company being represented:
(Edad):
Legal age
Sex (Kasarian): Citizenship (Pagkamamamayan): Filipino
If foreigner indicate Passport or ACR NO. : ____________
Male (Lalaki) ✔️Female (Babae)
Civil Status: Occupation (Trabaho):
Private Government
Married Single ✔️ Others (Pls. Specify): _________________
Others (Pls. Specify): _________________ Profession (Propesyon):_________________

Present Address (Kasalukuyang Tirahan): Permanent Address (Permanenteng Tirahan):

#80 Guzman Street, Manduarriao, Iloilo City

Telephone/Mobile Number (Telepono): E-mail Address:

Other Information: If a member of Law Enforcement Agency:

Person with Disability/May Kapansanan Position:__________________________
Senior Citizen/Nakakatandang Mamamayan Name of Agency:___________________
Ethnic Affiliation/Tribo (Pls. Specify): ________________

Offense (Krimen): Counts (Bilang):

Trespass to Property under Article 281, Grave Coercion
under Article 286, and Malicious Mischief under Articles
327 to 331 of the Revised Penal Code
Date and Time of Commission (Petsa at oras ng pangyayari): Place of Commission (Lugar ng pinangyarihan):
. Tacurong City

Witnesses (Saksi)
Last Name(Apelyedo): Middle Name (Gitnang Pangalan):
ORCAJADA SANTIAGO
First Name (Unang Pangalan): Address (Tirahan):
RONNIE Purok 2, Barangay Rajah Muda, Tacurong City

Documents and Evidence Submitted:

Joint-Complaint Affidavit Falsified Affidavit of Loss
Certificate of Death Affidavit of Witness
Deed of Absolute Sale _______________________________________________
Acknowledgment Receipt _______________________________________________
Duplicate Copy of Title of Transfer Certificate Title _______________________________________________
Special Power of Attorney _______________________________________________

1. Has a similar complaint been filed before any other office? *

Yes No✔️
2. Is this complaint in the nature of a counter-charge?*
If yes, indicate details._______________________________ Yes No✔️
3. Is this complaint related to another case filed before this Office?*
If yes, indicate details._______________________________ Yes No✔️
4. Is there a minor complainant/victim or respondent?
Yes No✔️
 C E R T I F I C A T I O N*

WE 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 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.

ERWIN D. GARCIA and RONALYN GRECIA

Complainant

SUBSCRIBED AND SWORN TO before me this 14 June 2024 in Tacurong City,Philippines.

Prosecutor Administering Oath

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

RESPONDENT INFORMATION (Impormasyon ng Nirereklamo)
Last Name(Apelyedo): Middle Name (Gitnang Pangalan):
TRAVILLA
First Name (Unang Pangalan): Alias (Alyas):
TONG-IT
Date of Birth (Kapanganakan): Age Corporation or Company being represented:
(Edad):
Legal age
Sex (Kasarian): Citizenship (Pagkamamamayan): Filipino
If foreigner indicate Passport or ACR NO. : ____________
✔️Male (Lalaki) Female (Babae)
Civil Status: Occupation (Trabaho):
Married Single Private Government
Others (Pls. Specify): _________________ Others (Pls. Specify): _________________
Profession (Propesyon):_________________
Present Address (Kasalukuyang Tirahan): Permanent Address (Permanenteng Tirahan):
AGAN HOME SAMPAO, ISULAN, SULTAN KUDARAT

Telephone/Mobile Number (Telepono): E-mail Address:

Other Information: If a member of Law Enforcement Agency:

Person with Disability/May Kapansanan Position:__________________________
Senior Citizen/Nakakatandang Mamamayan Name of Agency:___________________
Ethnic Affiliation/Tribo (Pls. Specify): ________________

RESPONDENT INFORMATION (Impormasyon ng Nirereklamo)

Last Name(Apelyedo): Middle Name (Gitnang Pangalan):
TRAVILLA
First Name (Unang Pangalan): Alias (Alyas):
AILYN
Date of Birth (Kapanganakan): Age Corporation or Company being represented:
(Edad):
Legal age
Sex (Kasarian): Citizenship (Pagkamamamayan): Filipino
If foreigner indicate Passport or ACR NO. : ____________
Male (Lalaki) ✔️Female (Babae)
Civil Status: Occupation (Trabaho):
Married Single Private Government
Others (Pls. Specify): _________________ Others (Pls. Specify): _________________
Profession (Propesyon):_________________
Present Address (Kasalukuyang Tirahan): Permanent Address (Permanenteng Tirahan):
AGAN HOME SAMPAO, ISULAN, SULTAN KUDARAT

Telephone/Mobile Number (Telepono): E-mail Address:

Other Information: If a member of Law Enforcement Agency:

Person with Disability/May Kapansanan Position:__________________________
Senior Citizen/Nakakatandang Mamamayan Name of Agency:___________________
Ethnic Affiliation/Tribo (Pls. Specify): ________________

RESPONDENT INFORMATION (Impormasyon ng Nirereklamo)

Last Name(Apelyedo): Middle Name (Gitnang Pangalan):
GRECIA
First Name (Unang Pangalan): Alias (Alyas):
JEAN
Date of Birth (Kapanganakan): Age Corporation or Company being represented:
(Edad):
Legal age
Sex (Kasarian): Citizenship (Pagkamamamayan): Filipino
If foreigner indicate Passport or ACR NO. : ____________
 Male (Lalaki) ✔️Female (Babae)
Civil Status: Occupation (Trabaho):
Married Single Private Government
Others (Pls. Specify): _________________ Others (Pls. Specify): _________________
Profession (Propesyon):_________________
Present Address (Kasalukuyang Tirahan): Permanent Address (Permanenteng Tirahan):
#80 GUZMAN STREET, MANDUARRIAO, ILOILO CITY

Telephone/Mobile Number (Telepono): E-mail Address:

Other Information: If a member of Law Enforcement Agency:

Person with Disability/May Kapansanan Position:__________________________
Senior Citizen/Nakakatandang Mamamayan Name of Agency:___________________
Ethnic Affiliation/Tribo (Pls. Specify): ________________
RESPONDENT INFORMATION (Impormasyon ng Nirereklamo)
Last Name(Apelyedo): Middle Name (Gitnang Pangalan):
CEPE
First Name (Unang Pangalan): Alias (Alyas):
INOCENCIA
Date of Birth (Kapanganakan): Age Corporation or Company being represented:
(Edad):
Legal age
Sex (Kasarian): Citizenship (Pagkamamamayan): Filipino
If foreigner indicate Passport or ACR NO. : ____________
Male (Lalaki) ✔️Female (Babae)
Civil Status: Occupation (Trabaho):
Married Single Private Government
Others (Pls. Specify): _________________ Others (Pls. Specify): _________________
Profession (Propesyon):_________________
Present Address (Kasalukuyang Tirahan): Permanent Address (Permanenteng Tirahan):
#80 GUZMAN STREET, MANDUARRIAO, ILOILO CITY

Telephone/Mobile Number (Telepono): E-mail Address:

Other Information: If a member of Law Enforcement Agency:

Person with Disability/May Kapansanan Position:__________________________
Senior Citizen/Nakakatandang Mamamayan Name of Agency:___________________
Ethnic Affiliation/Tribo (Pls. Specify): ________________

RESPONDENT INFORMATION (Impormasyon ng Nirereklamo)

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

First Name (Unang Pangalan): Alias (Alyas):

HAROLD
Date of Birth (Kapanganakan): Age Corporation or Company being represented:
(Edad):
Legal age
Sex (Kasarian): Citizenship (Pagkamamamayan): Filipino
If foreigner indicate Passport or ACR NO. : ____________
✔️Male (Lalaki) Female (Babae)
Civil Status: Occupation (Trabaho):
Married Single Private Government
Others (Pls. Specify): _________________ Others (Pls. Specify): _________________
Profession (Propesyon):_________________
Present Address (Kasalukuyang Tirahan): Permanent Address (Permanenteng Tirahan):
PRK. 3, BRGY. RAJAH MUDA, TACURONG CITY, SULTAN
KUDARAT
Telephone/Mobile Number (Telepono): E-mail Address:

Other Information: If a member of Law Enforcement Agency:

Person with Disability/May Kapansanan Position:__________________________
Senior Citizen/Nakakatandang Mamamayan Name of Agency:___________________
Ethnic Affiliation/Tribo (Pls. Specify): ________________

RESPONDENT INFORMATION (Impormasyon ng Nirereklamo)

Last Name(Apelyedo): Middle Name (Gitnang Pangalan):
First Name (Unang Pangalan): Alias (Alyas):
GEO
Date of Birth (Kapanganakan): Age Corporation or Company being represented:
(Edad):
Legal age
Sex (Kasarian): Citizenship (Pagkamamamayan): Filipino
If foreigner indicate Passport or ACR NO. : ____________
✔️Male (Lalaki) Female (Babae)
Civil Status: Occupation (Trabaho):
Married Single Private Government
Others (Pls. Specify): _________________ Others (Pls. Specify): _________________
Profession (Propesyon):_________________
Present Address (Kasalukuyang Tirahan): Permanent Address (Permanenteng Tirahan):
PRK. 3, BRGY. RAJAH MUDA, TACURONG CITY, SULTAN
KUDARAT
Telephone/Mobile Number (Telepono): E-mail Address:

Other Information: If a member of Law Enforcement Agency:

Person with Disability/May Kapansanan Position:__________________________
Senior Citizen/Nakakatandang Mamamayan Name of Agency:___________________
Ethnic Affiliation/Tribo (Pls. Specify): ________________