Republic of the Philippines

Department of Justice
OFFICE OF THE PROVINCIAL PROSECUTOR OF BATAAN
Balanga City Bataan

INVESTIGATION DATA FORM

To be Accomplished by the Office

DATE RECEIVED: ____________________ NPS DOC NO. ______________________

Time Received: _______________________ Assigned to ________________________
Receiving Staff ________________________Date Assigned _____________________

To be accomplished by complainant /counsel/law enforcer

(Use back portion if space is not sufficient)
COMPLAINANT: Name, Sex, Age, RESPONDENT: Name, Sex, Age, Address
Address

Shirlyn Medina y Sarmiento, female, Nestor Capinpin y Gamboa, male, legal

43 years old and resident of no. 1644 age and resident of Brgy. Maluid, Victoria
Porto Gate, Brgy. Balon Anito, Tarlac
Mariveles, Bataan

OFFENSE/s COMMITTED /LAW/VIOL WITNESESS: Name and Address

Jessie James Manaytay y Abella and
Other Deceit resident of no. 1644 Porto Gate, Brgy.
Balon Anito, Mariveles, Bataan

DATE AND TIME OF COMISSION PLACE OF COMMISSION

At no. 1644 Porto Gate, Brgy. Balon
April 20, 2023 at about 6:00PM Anito, Mariveles, Bataan

1. Has similar complaint been filed before any other offices? *YES ____NO x____
2. Is this complaint in the nature of counter-affidavit?* YES_____NO__x__ If yes, indicate
details below
3. Is this complaint related to another case before this office?*YES ____NO _x__ if yes, indicate
details below
I. S. NO.: ___________________________________
Handling Prosecutor __________________________

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

Shirlyn Medina y Sarmiento

(Signature over printed name)

SUBSCRIBED AND SWORN TO before me this ____ day of October 2023 in Balanga
City, Bataan.

Republic of the Philippines

 Department of Justice
OFFICE OF THE PROVINCIAL PROSECUTOR OF BATAAN
Balanga City Bataan

INVESTIGATION DATA FORM

To be Accomplished by the Office

DATE RECEIVED: ____________________ NPS DOC NO. ______________________

Time Received: _______________________ Assigned to ________________________
Receiving Staff ________________________Date Assigned _____________________

To be accomplished by complainant /counsel/law enforcer

(Use back portion if space is not sufficient)
COMPLAINANT: Name, Sex, Age, RESPONDENT: Name, Sex, Age, Address
Address

Shirlyn Medina y Sarmiento, female, Nestor Capinpin y Gamboa, male, legal

43 years old and resident of no. 1644 age and resident of Brgy. Maluid, Victoria
Porto Gate, Brgy. Balon Anito, Tarlac
Mariveles, Bataan

OFFENSE/s COMMITTED /LAW/VIOL WITNESESS: Name and Address

Jessie James Manaytay y Abella and
Other Deceit resident of no. 1644 Porto Gate, Brgy.
Balon Anito, Mariveles, Bataan

DATE AND TIME OF COMISSION PLACE OF COMMISSION

At no. 1644 Porto Gate, Brgy. Balon
April 20, 2023 at about 6:00PM Anito, Mariveles, Bataan