Republic of the Philippines

Department of the Interior and Local Government

PHILIPPINE NATIONAL POLICE
Sta. Cruz Municipal Police Station

COMPLAINT SHEET

Complaint No.________________ Date:5/19/21

1. REPORTED THRU: 2. Previously Reported to other agency:
[  ] In Person [ ] Yes [  ] No
[ ] Telephone If yes;
[ ] Other a. To what agency
_____________________________
b. BY whom
__________________________________
c. Date/time
__________________________________

3. Nature of Complaint/Info 4. Place of Occurrence/Incident 5. Date/time

Murder Brgy. Patimbao Sta. Cruz, 5-19-21/6

Laguna PM
onwards
6. Name of Complainant/Informer 7. Address 8. Tel No.
Rogelio S. Dela Cruz Brgy. Patimbao Sitio 7 Sta.
Cruz, Laguna

9. Name(s) of Victim(s) 10. Age 11.Sex 12. Address 13. Tel No.

Antonio S. Dela Cruz 22 M Brgy. Patimbao Sitio 7

Sta. Cruz, Laguna

14. Name(s) of Suspect(s) 15. Alias 16.Sex 17.Age 18. Address

Wilberto K. Capili Willie Boy M 26 Brgy. Patimbao
Sitio 7 Sta. Cruz,
Laguna

19. Name(s) of Witness(es) 20. Address 21. Tel No.

Brgy. Patimbao Sitio 6 Sta.
Lamberto P. Osmena
Cruz, Laguna
Brgy. Patimbao Sitio 7 Sta.
Edward P. Tuyor
Cruz, Laguna
22. Brief facts/narrative of complaint (Use back page, if necessary)

The witnesses while standing out at the front of a sari-sari store saw a man lurking at the
dark that they recognized as Wilberto K. Capili holding a bolo but the two eyewitness
disregarded it. After 15 minutes Antonio Dela Cruz appear to be walking towards the dark
where Wilberto Capili is lurking. After Antonio Dela Cruz gets close to Lamberto, he
suddenly hacks Antonio with his bolo 2 times on the neck and then he ran away fast to
hide.

23. Remarks of the receiving officer (especially if reporter refused to be identified):

a. Dialect (Accent): Tagalog_______________________________

b. Female/Male: Male _______________________________
c. Possible Age: _over 25__________________________
d. Possible place where the caller is: __________________________________
e. Intoxicated or not: _NOT______________________________________________
f. Others:: _________________________________________________________

24. I certify that the details of the 25. SUBSCRIBED AND SWORN to before
complaint/info stated above are true and me this 19th Day of May 2021 at Sta.
correct to the best of my knowledge. Cruz Municipal Police Station

______ Rogelio S. Dela Cruz__________

Printed Name & Signature of Complainant/Informer

26. Date/Time/Complaint/Info Received 27. Printed name/Signature of Receiving

5-19-21/7:00 PM/Murder/ Officer
Gilber O. Faller_______

28. Assigned to: 29. Noted by:

Police Corporal James S. Bond Police Lt. Vincent M. Pelaez

CONFIDENTIAL