Republic of the Philippines
National Police Commission
Quezon City Police Station
123 Main Street, Quezon City
Tel. No: 123-4567
Email: qc.police@email.ph
Incident Report
Report Number: QC-2023-001
Date: January 15, 2023
I. Incident Information
Date and Time of Incident: January 14, 2023, 20:30
Location: 456 Oak Street, Barangay Central, Quezon City
II. Complainant/Reporting Party Information
Name: Juan Dela Cruz
Address: 789 Pine Avenue, Barangay East, Quezon City
Contact Number: 987-6543
III. Involved Parties
A. Suspect(s)
1. Name: Roberto Santos
2. Address: 101 Maple Lane, Barangay West, Quezon City
3. Date of Birth: March 5, 1980
4. Other Identifying Information: Tattoo on left forearm
B. Victim(s)
1. Name: Maria Dela Cruz
2. Address: 789 Pine Avenue, Barangay East, Quezon City
3. Contact Number: 987-6543
IV. Witnesses
1. Name: Elena Gomez
Address: 567 Cedar Road, Barangay North, Quezon City
Contact Number: 876-5432
V. Narrative/Description of the Incident
On January 14, 2023, at approximately 20:30, the complainant, Juan Dela Cruz, reported an incident of
domestic violence involving the suspect, Roberto Santos. The complainant stated that an argument
escalated into physical violence, and Roberto Santos allegedly assaulted Maria Dela Cruz, causing visible
injuries.
VI. Evidence
Photographs of Maria Dela Cruz's injuries were taken at the scene.
VII. Statements
A. Complainant's Statement
Juan Dela Cruz reported that the argument started over a family matter and escalated into physical
violence.
B. Suspect's Statement
Roberto Santos denied the allegations and claimed that he acted in self-defense.
C. Witness Statement
Elena Gomez witnessed the altercation and confirmed that she saw Roberto Santos physically
assaulting Maria Dela Cruz.
VIII. Officer's Observations
Upon arrival at the scene, Officer Rodriguez observed Maria Dela Cruz with visible injuries consistent
with assault.
IX. Charges/Crimes
Roberto Santos was charged with violation of Republic Act 9262 (Anti-Violence Against Women and
Their Children Act of 2004).
X. Arrest Information
Roberto Santos was placed under arrest on January 14, 2023, at 21:15, at 456 Oak Street.
XI. Disposition/Action Taken
Maria Dela Cruz was provided with information on obtaining a protection order. Roberto Santos was
transported to the Quezon City Police Station for processing.
XII. Conclusion/Summary
The incident was resolved with the arrest of Roberto Santos, and appropriate legal actions were taken.
XIII. Prepared by
Officer Maria Rodriguez
Police Officer 2
Badge/ID Number: QC-12345
Attachments:
- Photographs of Maria Dela Cruz's injuries
- Sketch of the incident location
[Officer's Signature]
January 15, 2023, 22:00