LTFRB COMPLAINT FORM

COMPLAINT RECEIVED THRU: Phone Text Walk In Mail/Email

DATE & TIME REPORTED ________________________________________________________________

COMPLAINANT INFORMATION

NAME _________________________________________________________________
CONTACT NO _________________________________________________________________
ADDRESS _________________________________________________________________

WILLING TO ATTEND HEARING IF NEEDED? YES NO

DETAILS

TYPE OF SERVICE (PUJ, TAXI, PUB, PUV etc) _____________________________________________

PLATE NO. __________________________ DATE & TIME OF INCIDENT: _______________________

PLACE OF INCIDENT ____________________________________________________________________
VIOLATIONS:
_______ Contracting Passengers
_______ Overcharging/Undercharging
 How much did you pay?__________ Place of Origin:____________ Destination:_____________
_______ Arrogant/Discourteous Driver
_______ Refusal to Convey Passenger
_______ Fast Meter
_______ No Flag down Meter
_______ Hit and Run
_______ Threatening Passenger
_______ Reckless Driving
_______ Discriminating Against Passenger
_______ Refusal to Grant Senior/Student Discount
_______ Others (Please Specify) __________________________________________________________

Other Information that can help the Investigation (if any):

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

VERIFICATION

I ______________________________, of legal age, after having been duly sworn to in accordance with
law, do hereby depose and state that: 1.) I am the complainant in this case: 2.) I prepared/caused the
preparation of this complaint: 3.) I have read the contents of the complaint and the facts stated herein
are true and correct of my personal knowledge and/or on the basis of copies of documents and records
in my possession.

______________________
Affiant