Philippine National Police
INCIDENT RECORD FORM
IRF ENTRY NUMBER: TYPE OF INCIDENT: COPY FOR:
2023-05-05-031 CONSUMATED MURDER COMPLAINANT
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:
MAY 5, 2023/9:15 AM MAY 5, 2023/9:10 AM BRGY. ABALANG STA. BARBARA, PANGASINAN
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
AGMUKAYA MELCHOR AGBUYA N/A NONE
CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (MM/DD/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE
FILIPINO MALE MARRIED 01/15/1988 35 DAGUPAN CITY
CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
43 LAS VEGAS DAGUPAN CITY PANGASINAN
OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS RELATION EMAIL ADDRESS (If Any)
HOGH SCHOOL GRADUATE COLLECTOR ABC LENDING INC CALASIAO PANGASINAN TO VICTIM
NONE
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?
5’8” 85KG MEDIUM BLACK BLACK □ NO DRUGS X 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
BALASUBAS LUIS SALVA NONE NONE
CITIZENSHIP SEX/GENDER CIVIL STATUS DATE OF BIRTH (MM/DD/YY) AGE PLACE OF BIRTH HOME PHONE MOBILE PHONE
FILIPINO MALE MARRIED 02/14/1990 33 SAN CARLOS CITY
CURRENT ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
11 ABALANG STA BARBARA PANGASINAN
OTHER ADDRESS (HOUSE NUMBER/STREET) VILLAGE/SITIO BARANGAY TOWN/CITY PROVINCE
HIGHEST EDUCATIONAL ATTAINMENT OCCUPATION WORK ADDRESS EMAIL ADDRESS (If Any)
HIGH SCHOOL GRADUATE CONSTRUCTION WORKER DPWH TULIAO STA. BARBARA PANGASINAN
ITEM “D” - NARRATIVE OF INCIDENT
TYPE OF INCIDENT DATE/TIME OF INCIDENT PLACE OF INCIDENT
CONSUMATED MURDER MATY 5, 2023/ 9:10 AM BRGY. ABALANG STA. BARBARA, PANGASINAN
ENTER IN DETAIL THE NARRATIVE OF THE INCIDENT OR EVENT, ANSWERING THE WHO, WHAT, WHEN, WHERE, WHY AND HOW OF REPORTING.
(DETAILS OF THIS NARRATIVE SHALL BE THE BASIS IN THE ENTRY OF RECORD IN THE POLICE
BLOTTER)
I HEREBY CERTIFY TO THE CORRECTNESS NAME OF REPORTING PERSON SIGNATURE OF REPORTING PERSON
OF 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 Telephone
Investigator-on-Case Mobile Phone
Name of Chief/Head
Mobile Phone
of Office
