Republic of the Philippines

Province of Cavite
City of Bacoor
Barangay Molino II
OFFICE OF THE PUNONG BARANGAY
Telephone No. (046) 477-1539
TERHEAD OF BARANGAY MOLINO – II, BACOOR CITY OFFICIAL LETTERHEAD OF BARANGAY MOLINO – II, BACOOR CITY OFFICIAL LETTERHEAD OF BARANGAY MOLINO – II, BACOOR CITY OFFICIAL LETTERHEAD OF BARANGAY MOLINO – II, BACOOR CITY OFFICIAL LETTERHEAD OF BARANGAY MOLINO –

No.
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BLOTTER FORM
Petsa ng Pagblotter: ________________________

A. Pangalan ng Nag- blo- blotter/Nagrereklamo:

TIRAHAN _____________________________________________________________________
Contact No. ____________________________________________________Edad___________

B. Pangalan ng Inerereklamo: ________________________________________________

TIRAHAN ______________________________________________________________________
Contact No. _____________________________________________________Edad __________

C. REKLAMO ____________________________________________________________________
D. KAGANAPAN NG PANGYAYARI: PETSA______________________________________________
ORAS ______________________________________________
LUGAR______________________________________________
E. SALAYSAY
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LAGDA NG SUMULAT NG SALAYSAY_________________________________________________

PANGALAN NG SUMULAT NG SALAYSAY_____________________________________________
PETSA ____________________________ ORAS________________________________
(MGA) TESTIGO: (Maaaring magsulat sa likod)
Pangalan ____________________________________________________Edad ______
Tirahan ______________________________________________________________
Contact No.___________________________________

Pangalan ng Barangay Desk Officer:_________________________________________

LAGDA NG BARANGAY DESK OFFICER: ______________________________________