Philippine National Police

INCIDENT RECORD FORM

IRF ENTRY NUMBER: TYPE OF INCIDENT: COPY FOR:
141110-20156-1736 Others/PHYSICAL INJURIES
INSTRUCTIONS: Refer to PNP SOP on ‘Recording of Incidents in the Police Blotter’ in filling up this form. This Incident Record Form (IRF) may be reproduced, photocopied,
and/or downloaded from the DIDM website, www.didm.pnp.gov.ph.
DATE AND TIME REPORTED: DATE AND TIME OF INCIDENT: PLACE OF INCIDENT:
6/3/2015 6:15 AM 6/2/2015 7:00 AM Wangal LA TRINIDAD (Capital) Benguet
ITEM “A” - REPORTING PERSON
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME

CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (MM/DD/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE

CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION ID CARD PRESENTED EMAIL ADDRESS (If Any)

ITEM “B” – SUSPECT’S DATA

FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME
Tino Cristina Ismael
CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (MM/DD/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE
FILIPINO Female Married Nawal, Bokod, Benguet
CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
PA 101, Motor Pool Wangal La Trinidad Benguet
OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS RELATION TO EMAIL ADDRESS (If Any)
FARMER VICTIM
Niece
IF AFP/PNP PERSONNEL: RANK UNIT ASSIGNMENT GROUP AFFILIATION WITH PREVIOUS CRIMINAL RECORD? STATUS OF PREVIOUS CASE
[ ] Yes [ ] No
(If Yes, Pls. Specify)

HEIGHT WEIGHT BUILT COLOR OF EYES DESCRIPTION OF EYES COLOR OF HAIR DESCRIPTION OF HAIR UNDER THE INFLUENCE?
NO DRUGS LIQUOR
OTHERS
________________________

FOR CHILDREN IN CONFLICT WITH THE LAW

NAME OF GUARDIAN GUARDIAN ADDRESS HOME PHONE MOBILE PHONE

ITEM “C” – VICTIM’S DATA

FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME

Belit Marivic Ismael

CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (MM/DD/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE

Filipino Female Single August 26, 1988 26 Nawal, Bokod, Benguet

CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

Housing Wangal La Trinidad BENGUET

OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE

HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS EMAIL ADDRESS (If Any)

GRADE IV
 ITEM “D” - NARRATIVE OF INCIDENT
TYPE OF INCIDENT DATE/TIME OF INCIDENT PLACE OF INCIDENT

6/3/2015 6:15 AM 6/2/2015 7:00 AM BENGUET LA TRINIDAD (Capital) Wangal

ENTER IN DETAIL THE NARRATIVE OF THE INCIDENT OR EVENT, ANSWERING THE WHO, WHAT, WHEN, WHERE, WHY AND HOW OF REPORTING.

Physical Injuries - Accordingly, the complainant was sitting beside the road when the suspect pass by and suddenly slapped
the left face of the complaint once without any aparent reason. The complainant further said that the suspect had harmed her
in the past years but she did not report the incident. IOC - SPO2 Pol-ocan, MA.

(DETAILS OF THIS NARRATIVE SHALL BE THE BASIS IN THE ENTRY OF RECORD IN THE POLICE BLOTTER)
I HEREBY CERTIFY TO THE CORRECTNESS OF NAME OF REPORTING PERSON SIGNATURE OF REPORTING PERSON
THE FOREGOING TO THE BEST OF MY
KNOWLEDGE AND BELIEF.
NAME OF ADMINISTERING OFFICER (DUTY OFFICER) SIGNATURE OF ADMINISTERING OFFICER (DUTY OFFICER)
SUBSCRIBED AND SWORN TO BEFORE ME

RANK, NAME AND DESIGNATION OF POLICE OFFICER (WHETHER HE/SHE IS THE DUTY INVESTIGATOR, SIGNATURE OF DUTY INVESTIGATOR/INVESTIGATOR ON CASE/ASSISTING
INVESTIGATOR ON CASE OR THE ASSISTING POLICE OFFICER) POLICE OFFICER

RANK/NAME OF DESK OFFICER: SIGNATURE OF DESK OFFICER: BLOTTER ENTRY NR:

INCIDENT RECORDED IN THE BLOTTER BY:

REMINDER TO REPORTING PERSON

Keep the copy of this Incident Record Form (IRF). An update of the progress of the investigation of the crime or incident that you reported
will be given to you upon presentation of this IRF. For your reference, the data below is the contact details of this police station.

Name of Police Station La Trinidad MPS Telephone

Investigator-on-Case SPO2 Mario A. Pol-ocan Mobile Phone

Name of Chief/Head of
Mobile Phone
Office