FOR POLICE BLOTTER ENCODER USE ONLY
BLOTTER ENTRY NUMBER
Philippine National Police
2015-0224
TYPE OF INCIDENT
RE ALLEGED SHOOTING INCIDENT
INCIDENT RECORD FORM
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:
FEBRUARY 24, 2015 5:00 PM FEBRUARY 24,2015 4:30 PM
ITEM “A” - REPORTING PERSON
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME
DOMINGO MARIA JOSEFA DAJES
CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE
FILIPINO FEMALE MARRIED 10/JANUARY/1975 40 LOS BAŇOS 0919-859-3260
CURRENT ADDRESS (HOUSE NUMBER STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
45 LOPEZ AVE. / MAQUILING SUBD. BATONG MALAKE LOS BAŇOS LAGUNA
OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION ID CARD PRESENTED EMAIL ADDRESS (If Any)
COLLEGE LEVEL HOUSEWIFE Driver License
ITEM “B” - SUSPECT DATA
CHECK HERE IF THERE IS NO SUSPECT INVOLVED AND THEREAFTER PROCEED TO ITEM “C”.
CHECK HERE IF THERE ARE TWO OR MORE SUSPECTS. THEREAFTER, USE ADDITIONAL INCIDENT REPORT FORM SHEETS FOR EACH OF THE SUSPECTS.
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME
FERNANDEZ FRANCISCO MEJIA BOY NEGRO
CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE
FILIPINO MALE MARRIED 10/JUNE/1980 35 CALAMBA CITY 0975-431-8101
CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
60 CHIPECO ST. PARIAN CALAMBA CITY LAGUNA
OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS RELATION TO VICTIM EMAIL ADDRESS (If Any)
HIGH SCHOOL GRADUATE DRIVER 45 LOPEZ AVE., MAQUILLING SUBD., CO-WORKER
BATONG MALAKE, LOS BAŇOS, LAGUNA
IF AFP/PNP PERSONNEL: RANK UNIT ASSIGNMENT GROUP AFFILIATION WITH PREVIOUS CRIMINAL RECORD? [ ] Yes [ ] No STATUS OF PREVIOUS CASE
(If Yes, Pls. Specify)
HEIGHT WEIGHT COLOR OF EYES DESCRIPTION OF EYES COLOR OF HAIR DESCRIPTION OF HAIR UNDER THE INFLUENCE?
5’6 75 KGS NO DRUGS LIQUOR
OTHERS ________________________
FOR CHILDREN IN CONFLICT WITH THE LAW
NAME OF GUARDIAN GUARDIAN ADDRESS HOME PHONE MOBILE PHONE
DIVERSION MECHANISM
OTHER DISTINGUISHING FEATURES (DESCRIBE IN DETAIL CLOTHES, VEHICLE, SUNGLASSES, WEAPON/S, SCARS, AND OTHER DATA OR ACTIVITY OF THE SUSPECT/S WHICH WERE OBSERVED BY THE
REPORTING PERSON AND/OR WITNESS/ES TO IDENTIFY THE SUSPECT/S. THESE ARE IMPORTANT AND MAY BECOME EVIDENCE TO IDENTIFY, AND LINK TO THE CRIME, THE SUSPECT/S. USE
ADDITIONAL SHEET/S IF NECESSARY)
--------------------------------------CUT HERE. ISSUE THIS RECEIPT TO THE REPORTING PERSON-------------------------------------------
BLOTTER ENTRY NUMBER
2015-0224 INCIDENT RECORD TRANSACTION RECEIPT
NAME OF REPORTING PERSON: ADDRESS OF REPORTING PERSON:
THIS CERTIFIES THAT MARIA JOSEFA DAJES DOMINGO 45 LOPEZ AVE., MAQUILING SUBD., BRGY BATONG MALAKE, LOS
BAŇOS, LAGUNA
REPORTED AN INCIDENT TO BE TYPE OF INCIDENT: RE ALLEGED SHOOTING INCIDENT
RECORDED IN THE POLICE BLOTTER
WHICH INVOLVES
AND
DATE/TIME OF REPORT: DATE/TIME OF INCIDENT: PLACE OF INCIDENT: RECORDED BY: P03. KLEIN P. QUILENDERINO
FEBRUARY 24, 2015 5:00 PM FEBRUARY 24,2015 4:30 PM LOPEZ AVE., BATONG MALAKE, LOS
BAŇOS, LAGUNA RANK/NAME/SIGNATURE OF DESK OFFICER
ITEM “C” – VICTIM DATA
CHECK HERE IF THE REPORTING PERSON (ITEM “A”) IS THE VICTIM. PROCEED TO ITEM “D”.
CHECK HERE IF THERE ARE TWO OR MORE VICTIMS. USE ADDITIONAL INCIDENT REPORT FORM SHEETS FOR THE DATA OF THE ADDITIONAL VICTIMS.
FAMILY NAME FIRST NAME MIDDLE NAME QUALIFIER NICKNAME
DOMINGO FERNANDO SAGPATAN
CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (DD/MM/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE
FILIPINO MALE MARRIED 5/JANUARY/1970 45 LOS BAŇOS 0917-694-7801
CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
45 LOPEZ AVE. MAQUILING SUBD. BATONG MALAKE LOS BAŇOS LAGUNA
OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS EMAIL ADDRESS (If Any)
COLLEGE LEVEL DRIVER 45 LOPEZ AVE., MAQUILLING SUBD., BATONG MALAKE,
LOS BAŇOS, LAGUNA
ITEM “D” - NARRATIVE OF INCIDENT
BLOTTER ENTRY NUMBER TYPE OF INCIDENT TIME DATE PLACE OF INCIDENT
2015-0224 RE ALLEGED SHOOTING INCIDENT 4:30 PM FEBRUARY 24, 2015 LOPEZ AVE., BATONG MALAKE, LOS
BAŇOS, LAGUNA
ENTER IN DETAIL THE NARRATIVE OF THE INCIDENT OR EVENT, ANSWERING THE WHO, WHAT, WHEN, WHERE, WHY AND HOW OF REPORTING. (USE ADDITIONAL SHEET/S IF NECESSARY)
Mrs. Maria Josefa Dajes Domingo, 40 years old, married, housewife, resident of 45 Lopez Ave. , Maquiling Subd. ,Brgy, Batong Malake Los
Baňos, Laguna reported an alleged shooting incident happen on February 24, 2015 at 4:30 o’clock in the afternoon at Lopez Ave., Maquiling, Los Baňos,
Laguna. The reporter said that the victim is Fernando Sagpatan Domingo, 45 years old, Married, Driver and a resident of the same barangay who was
sustained 5 gunshot wounds, chest. The victim was immediately rushed to the nearest hospital but declared dead on arrival. The suspect also identified
as Francisco Meija Fernandez a.k.a “Boy Negro”, 35 years old, married, driver, co-worker of the victim and a resident of 60 Chipeco ST., Parian, Calamba
City, Laguna who was arrested by the Police Officers and now under their custody. The weapon used was a firearm of Caliber .45 with unknown SN. And
recovered 5 slugs of caliber .45. At 4:00 PM , the victim and suspect was having a drinking session, At 4:20 PM, the victim was caught texting the wife of
the suspect, 4:25 PM, the victim was already drunk and fell asleep, 4:30 PM, the suspect was started to shoot the victim, 4:35 PM, the suspect left the
crime scene and 4:40 PM, The suspect was caught and arrested by the police.
(DETAILS OF THIS NARRATIVE SHALL BE THE BASIS IN THE ENTRY OF RECORD IN THE POLICE BLOTTER)
AUTHENTICATION
I HEREBY CERTIFY TO THE CORRECTNESS OF THE NAME/SIGNATURE OF REPORTING PERSON NAME/SIGNATURE OF DESK OFFICER
FOREGOING TO THE BEST OF MY KNOWLEDGE AND
BELIEF. KLEIN P. QUILENDERINO
MARIA JOSEFA DAJES DOMINGO
CASE DISPOSITION (For Chief/Head of Office Use Only)
CHIEF Of STATION/OFFICE INSTRUCTIONS NAME OF DESIGNATED INVESTIGATOR-ON-CASE NAME OF CHIEF OF STATION/OFFICE
SPO2. MANUEL K. SUNGIT COP. KENNETH U. NAUMA
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INSTRUCTIONS TO REPORTING PERSON
Keep this Incident Record Transaction Receipt (IRTR). 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 IRTR. For your reference, the data below is the contact details of this police station.
Name of Police Station LOS BAŇOS POLICE STATION Telephone 0967-333-3333
Investigator-on-Case SPO2. Manuel K. Sungit Mobile Phone 0969-696-6969
Name of Chief/Head of Office COP. Kenneth U. Nauma Mobile Phone 0911-111-1111
