ACTA DE ENTREVISTA AL IMPUTADO / VICTIMA / TESTIGO

INICIO: Lugar \ Da \ Mes \ Ao y Hora: _____________________________________________________

I. DATOS GENERALES
Apellido paterno: ________________________, Apellido materno______________________
Nombre (s) _________________________________________________________________
Documento de identidad: DNI ____ LM _____ Pasaporte _____ Partida de Nacimiento ____
Carn de extranjera _____ otros ______ N__________________________
Sexo: M ______ F _______
Fecha de Nacimiento (d/m/a): _________/_________/___________Edad:______________
Lugar de Nacimiento: Pas____________________________________________________
Dpto. _________________________________, Prov. _______________________________
Ciudad_____________________________________________________________________
Distrito____________________________________
Estado Civil: Casado ____ Divorciado ____ Conviviente ___ Soltero ___ Separado ____
Otros _____________________________________________________________________
Nivel de Instruccin__________________________________________________________
Direccin Domiciliaria________________________________________________________
___________________________________________________________________________
Direccin de Notificacion_____________________________________________________
___________________________________________________________________________
Telfono de Contacto _______________, Correo Electrnico________________________
Profesin__________________________________Ocupacin________________________
Relacin con la vctima: Si _____ No ______
Con el (la) denunciante Si _____ No _____
Con el (la) denunciado (a) Si ______ No ______
Especifique_________________________________________________________________
___________________________________________________________________________

Caractersticas fsicas: (Describir) _______________________________________________

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

II. RELATO DE LOS HECHOS: (particip \ presenci \ conoci)

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
 ___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Se le informo que se utiliz medios tcnicos para el registro de la entrevista SI _____ NO _______
Lugar \ Ao \ Mes \ Da y Hora: _____________________________________________________

Firma _________________________________________

______________________________________________
DNI. Nro. ______________________________________

PERSONAL PNP EL REPRESENTANTE DEL

MINISTERIO PBLICO

_________________________________ _____________________________
 ACTA DE ENTREVISTA AL IMPUTADO / VICTIMA / TESTIGO

INICIO: Lugar \ Da \ Mes \ Ao y Hora: _______________________________________________

III. DATOS GENERALES

Apellido paterno: ________________________, Apellido materno______________________
Nombre (s) _________________________________________________________________
Documento de identidad: DNI ____ LM _____ Pasaporte _____ Partida de Nacimiento ____
Carn de extranjera _____ otros ______ N__________________________
Sexo: M ______ F _______
Fecha de Nacimiento (d/m/a): _________/_________/___________Edad:______________
Lugar de Nacimiento: Pas____________________________________________________
Dpto. _________________________________, Prov. _______________________________
Ciudad_____________________________________________________________________
Distrito____________________________________
Estado Civil: Casado ____ Divorciado ____ Conviviente ___ Soltero ___ Separado ____
Otros _____________________________________________________________________
Nivel de Instruccin__________________________________________________________
Direccin Domiciliaria________________________________________________________
___________________________________________________________________________
Direccin de Notificacion_____________________________________________________
___________________________________________________________________________
Telfono de Contacto _______________, Correo Electrnico________________________
Profesin__________________________________Ocupacin________________________
Relacin con la vctima: Si _____ No ______
Con el (la) denunciante Si _____ No _____
Con el (la) denunciado (a) Si ______ No ______
Especifique_________________________________________________________________
___________________________________________________________________________

Caractersticas fsicas: (Describir)

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

IV. RELATO DE LOS HECHOS: (particip \ presenci \ conoci)

___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Cdigo nico de carpeta Fiscal

 Prioridad
Distrito Judicial
Ministerio Pblico
Fiscala de la Nacin
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________

Se le informo que se utiliz medios tcnicos para el registro de la entrevista SI _____ NO _______
Lugar \ Ao \ Mes \ Da y Hora:
______________________________________________________

Firma ___________________________________

___________________________________________
DNI. Nro. ___________________________________

Firma (S) _________________________________ CIP ___________________

Cargo: _________________________