C O M P L A I N T    S H E E T
 
 
1. Complainant (Nagsusumbong):
    Address:
    Telephone:
 
2. PERSONS COMPLAINED AGAINST OR SUSPECTS (Isinusumbong)
 
       Name:
       Address:
       Telephone:
       Sex:
       Civil Status:
       AGE:
       Occupation (Hanap-buhay):
 
       * FOR MORE SUSPECTS, ENTER THEIR NAMES HERE:

 
3. NATURE OF ACT COMPLAINED OF (Uri ng sumbong):  
4. WHERE & WHEN COMMITTED (SAAN AT KAILAN NANGYARI):
   
5. VICTIMS if any:
 
       Name:
       Address:
       Telephone:
       Sex:
       Civil Status:
       AGE:
       Occupation (Hanap-buhay):
 
       * FOR MORE VICTIMS, ENTER THEIR NAMES HERE:

 
6. NARRATION OF FACTS (Salaysay ng mga Pangyayari):
 
     
7. HAS THE MATTER BEEN REPORTED TO ANY AGENCY? IF SO, TO WHAT POLICE AGENCY? (Ang bagay bang ito ay naulat na sa ibang sangay ng pagsisiyasat? Kung naulat na, saang Sangay?):
 
     
    STATUS OF INVESTIGATION, IF ANY (Kalagayan ng Pagsisiyasat kung mayroon)?:
 
     
8. IS THE MATTER COMPLAINED OF THE SUBJECT OF ANY COURT ACTION OR PROCEEDINGS? IF SO, WHERE? (Ang bagay bang may kinalaman sa pagsusumbong ay nasa hukuman na? Kung ganoon, saan?):
 
     
9. WHAT CONSIDERATION/S IMPELLED YOU TO REPORT TO THE NBI? (Ano ang nag-udyok sa iyo para magreklamo dito sa NBI?):
 
     
I CERTIFY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT ACCORDING TO THE BEST OF MY KNOWLEDGE AND BELIEF. (PINATUTUNUYAN KO ANG BUONG KATOTOHANAN NG MGA NAKASAAD DITO, BATAY SA AKING NABABATID AT PANIWALA.
 




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