OMB Form 4 - November 2020

FOR OMB USE:

Republic of the Philippines OMB FORM 4 CONTROL NO.: ___________
Office of the Ombudsman Date and Time Received:
Receiving Officer:

REQUEST FOR COMPLAINT/CASE INFORMATION (OMB Form 4)

Date of Request:

Sex:
Last Name First Name Middle Name

Address:
House No./Blk. No. Street Name Barangay

City/ Municipality Province Zip Code

Contact Number/s:
Mobile Landline

Please check one box:

Complainant Counsel Authorized Others, please specify

Representative
Respondent/Accused

OMB Case/Reference No.:

Case Title:

Specify purpose of request for non-parties:

Valid identification (ID) card/s presented

Identification Card presented by the REQUESTER Identification Card presented by the REPRESENTATIVE
Type ID Number Issuing Agency/Company Type ID Number Issuing Agency/Company

I declare that the answers given above are true and correct to the best of my knowledge and belief. By signing below, I agree to the Ombudsman Privacy Policy and
give my consent to the collection and processing of my personal data in accordance thereto.

_______________________________________________________________________________________
Signature Over Printed Name of Client
TO BE ACCOMPLISHED BY OMB PERSONNEL

Status of the Referred to other agency

Complaint/Case Under evaluation

OMB-Central OMB-Luzon OMB-Visayas Public Assistance Bureau

OMB-Mindanao OMB-MOLEO

Under preliminary investigation Under administrative adjudication

PI resolved on ______________________ AA decided on _______________________

With pending Motion for Reconsideration

MR resolved on:
For prosecution
Sandiganbayan
Other Courts

Remarks:

VERIFIED BY: RECEIVED BY:

Signature Over Printed Name Signature Over Printed Name of Client

_______________________________ _______________________________

Date Verified Date Verified

THIS FORM IS NOT FOR SALE. THIS CAN ALSO BE DOWNLOADED THRU THE OMBUDSMAN WEBSITE AT www.ombudsman.gov.ph