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DEPARTMENT OF JUSTICE
NATIONAL PROSECUTION SERVICE
Office of the Secretary
Padre Faura St., Ermita, Manila
________________________,
Complainant-Appellant,
- versus - for
________________
________________________,
Respondent-Appellee.
x - - - - - - - - - - - - - - - - - - - - - - -x
1. That on _________ the undersigned Chief of Police of ___(state the unit and postal address)___ upon
complaint of the private offended party filed a case against ___(state the name and postal address of the
respondent)__ for __(designation of offense) _ docketed under IS No. ____ before the Office of Honorable _________
located in ______ where the preliminary investigation took place;
2. That for the information of the Honorable Secretary this case started __(give the concise facts of the case)___
3. That on _____(date)___ the undersigned received the Resolution of the Honorable Prosecutor copy of which is
attached as Annex “A” disposing the case as follows:
4. That the undersigned ______(give your analysis how the Prosecutor disposed the case) ___.
5. That with due respect to the Honorable Prosecutor, the undersigned believed that he committed error on the
following:
WHEREFORE, the undersigned respectfully prays for the setting aside of the appealed resolution of Prosecutor
__________ dated _____and that the honorable prosecutor be directed to fileinformation ____(cite the relief that you
want if you have any)_____
____Place________. ____Date_____.
______________________
Chief of Police
VERIFICATION
JURAT
Copy furnished:
- Prosecutor
- Respondent
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