Republic of the Philippines

Department of Justice
NATIONAL PROSECUTION SERVICE
OFFICE OF THE PROVINCIAL PROSECUTOR
MALOLOS CITY, BULACAN

INVESTIGATION DATA FORM

To be accomplished by the office;

DATE RECEIVED: March 24, 2023 NPS DOCKET NO. 0001

(Stamped and initialled) _________________

Time Received: 3:00 pm Assigned to:____________________________________
Receiving Staff: ________________________ Date Assigned:_________________________________
_____________________________________________________________________________________
To be accomplished by complainant/counsel/law enforcer
(Use back portion if space is not sufficient)

COMPLAINANT/S: RESPONDENT/S:
IBARRA INFANTEZ, Male, 59 years old PADRE SALVI, Male, 40 years old, Panasahan,
MARIA CLARA INFANTEZ, Female, 57 years old Malolos, Bulacan
KLAY INFANTEZ, (Deceased), Female, 28 years old, San Isidro,
Paombong, Bulacan WITNESS/ES: Name & Address
Shaina Sarmiento, Malolos, Bulacan
Abraham Aguilera, Malolos, Bulacan
OFFENSE/S COMMITED/LAW/s VIOLATED:
PLACE OF COMMISSION:
Reckless Imprudence Resulting to Homicide
Malolos Highway, Malolos, Bulacan
DATE & TIME of COMMISSION:
March 24, 2023, 2:00 pm

1.) Has a similar Complaint been filed before any other office? YES___NO___
2.) Is this Complaint in the nature of a counter charge? YES___NO___If yes, indicate details below
3.) Is this Complaint related to another case before this office? YES___NO___ If yes, indicate details below

I.S./NPS Docket No.___________________________

Handling Prosecutor:__________________________

WE CERTIFY, under the oath, that all the information on this sheet is true and correct to the best of our
knowledge and belief, that we have not commenced any action or filed any claim involving the same issues in any
court, tribunal, or quash judicial agency and that if we should thereafter learn that a similar action has been filed
and/or pending, we shall report the fact to this Honorable Office within five (5) days from knowledge thereof.

IBARRA INFANTEZ
(Signature over printed name)

SUBSCRIBED AND SWORN TO before me this _____________________ in _______________________.

JOSSA B. REYES
Administering Prosecutor/ Officer