Republic of the Philippines )

Municipality of Catarman ) SS
x-------------------------------x

COMPLAINT AFFIDAVIT

I, A, Filipino, of legal age and a resident of Brgy. X,

Municipality of Y, Province of Z, after having been duly
sworn to in accordance with law, hereby depose and state,
thus:

1. That I am formally filing a criminal case for

MALICIOUS MISCHIEF defined under the revised penal
code against B, C and D, all of legal age, Filipino,
and residents of Brgy. X, Y, Z, which they committed
as follows:

2. I am the owner of our certain parcel of land covered

by Tax Declaration No. 12345, situated at Brgy. X, Y,
Z. Copy of said Tax Declaration is here to attach and
marked as Annex “A”, made an integral part hereof;

3. That on December 20, 2020 B and C destroyed my fence

as ordered by D;

4. That B, C and D are also residents of Brgy. X,

Municipality of Y, Province of Z;

5. That the estimated cost of the damage was around EIGHT

THOUSAND (P8,000.00) PESOS Philippine currency;

6. That a day prior to the incident, I saw sign boards

placed inside my fenced property by B and C, also
ordered by D with words “Isang bala ka lang”, attached
here to is a photo of the sign boards marked as Annex
“B” and made an integral part hereof;

7. That both incidents where witnessed by my worker, E;

8. That I report to the incident to Y Police Station, X,

Y, Z, attached here to this copy of police blotter,
marked as Annex “C” and made an integral part hereof;
 9. That, I am executing this complaint affidavit for
purposing of filing a criminal case against B, C and
D.

10.That, further, affiant sayeth naught.

IN WITNESS WHEREOF, I have hereunto set my hand this

th
5 day of February, 2021, at the Office of the Provincial
Prosecutor, Bulwagan Ng Katarungan, Y, Z, Philippines.

A
Affiant-complainant

SUBSCRIBED AND SWORN TO before me this 6th day of

February, 2021, at Y, Z, Philippines.

Doc. No. _______;

Page No._______;
Book No._______;
Series of 2021
NPS Investigation Form No. 01, s. 2008

Republic of the Philippines

DEPARTMENT OF JUSTICE
NATIONAL PROSECUTION SERVICE
OFFICE OF THE PROVINCIAL PROSECUTOR
Y, Z

INVESTIGATION DATA FORM

To be accomplished by the Office

DATE RECEIVED: ___________________________ NPS DOCKET

NO. __________________
(stamped & initial): _________________________
Assigned to: ______________________
Time Received: ____________________________ Date
assigned: ____________________
____________________________________________________________
_________________________

COMPLAINANT/S: (Name, Sex & Address)

RESPONDENT/S:(Name, Sex, Age & Add.)
A of legal age, male, B, C, D, all of
legal age,
Brgy. X, Y, Z. Brgy. X, Y, Z.
_________________________________

_________________________
________

LAW/S VIOLATED: WITNESESS/ES: Name

& Address

MALICIOUS MISCHIEF, DEFINED AND E, Brgy. X, Y, Z.

PENALIZED UNDER THE REVISED PENAL Others reserved
CODE
____________________________
____________________________________
DATE & TIME OF COMMISSION: PLACE
OF COMMISSION:

December 20, 2020 Brgy. X, Y, Z.

1. Has a similar complaint been filed before any other

office? YES_____ NO_X
2. Is this complaint in the nature of a counter-affidavit?
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.

NPS DOCKET NO.

____________________
Handling
Prosecutor: ____________________

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

I 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
claims 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 (5)
days from knowledge thereof.

(Signature over printed name)

SUBSCRIBED AND SWORN to before me this 6th day of February 2021 in Y, Z.