2023.09.01 Complaints Assisted Form 1 2

Republic of the Philippines
NATIONAL PRIVACY COMMISSION

5th Floor, Philippine International Convention Center,
Vicente Sotto Avenue, Pasay City, Metro Manila 1307
COMPLAINTS AND INVESTIGATION DIVISION
COMPLAINTS-ASSISTED FORM
REMINDERS: Complaints that are insufficient in form and in substance

may cause the outright dismissal of your complaint. To avoid that:
1. Always fill out the Complaints-Assisted Form legibly, completely

and accurately.
2. Do not forget to attach all your evidence/proof to support your
complaint.
3. Submit ONE COMPLAINT FORM PER RESPONDENT.
4. Provide us with a valid government issued I.D. List of accepted
government issued IDs:
• Philippine Passport • Voter’s ID
• Philippine Driver’s License • GSIS Card
• PRC ID • SSS Card
• Postal ID • TIN Card
• Student ID
PRIVACY NOTICE: We collect the following personal information from

you when you manually or electronically submit to us your complaint/s:
Full Name, Home address (Full Address see CAF Form), E-mail address, Contact
number, ID information.
USE: The collected personal information will be utilized solely for

documentation and processing of your complaint/s within the NPC and,
when appropriate, endorsement to other government agency/ies that
has/have jurisdiction over the subject of your complaint.
PROTECTION MEASURES: Only authorized NPC personnel has access

to this personal information, the exchange of which will be facilitated
through email and hard copy. NPC will only retain personal data as long
as necessary for the fulfillment of the purpose.
NPC_LEO_CID_CAF-V4.0, R1.0, 01 September 2023

URL: https//www.privacy.gov.ph Email Add: [email protected] Tel No. 8234-2228
Page 2
COMPLAINANT INFORMATION
Name:
Complete Address: Unit/Room/Floor/Bldg. No. Building Name/Tower
purok sampaguita rosario village
Lot/Block/Phase/House No. Street Name
purok sampaguita
Subdivision/Village/Zone, Barangay
rosario village ilayang iyam
Town/District
pucena
Municipality/City Province
lucena city quezon
Zip Code
4301
E-mail address: [email protected]
Contact number: 09485265088
Female Male
RESPONDENT INFORMATION
Name:
Complete Address: Unit/Room/Floor/Bldg. No. Building Name/Tower
Lot/Block/Phase/House No. Street Name
Subdivision/Village/Zone, Barangay
Town/District
Municipality/City Province
Zip Code
E-mail address:
Contact number:
Female Male
ALLEGATIONS: Personal information that respondent has processed:

(List the personal information processed. Examples of personal information: name,
age, address, marital status, email address)
1. online loan app

2. pesoloan
3. pautang peso
4. pesoredeee
5.

Page 3
EXHAUSTION OF REMEDIES
Contacted respondent, in writing, to allow respondent

to act on the complaint
Attach as supporting documents, any and all correspondence with the

respondent on the matter complained: (Please list and properly identify all
documents attached)
1.
2.
3.
4.
5.
Did not contact respondent. State reason:
VIOLATION SUBJECT OF COMPLAINT (Tick the box/es that may apply)
Sec. 25 Unauthorized Sec. 28. Processing for

Processing Unauthorized Purposes
Sec. 26. Access due to Sec. 31. Malicious

Negligence Disclosure
Sec. 27. Improper Disposal Sec. 32. Unauthorized

Disclosure
Date and Time of the Incident: 1pm-2am
Place of Incident: tawag lang po ng tWag wlaang tigil

Page 4
Narration of Facts: (Explain how the respondent committed a privacy violation)

kinokontack po lahat ng nasa phone book ko kahit diko n po gingwang reffernce sanila grabe
po pang haharass nila sa tex at sa tawag sobrang laki po nang bawas o kaltas.nila sa
nahiram.ko sa knila gsto ko naman po ibalik ayaw naman po nila. na stress na pk ako sa
kakaisip pinagmumura pa po ako sa tawag.
Supporting documents attached: (Please list and properly identify all the
attached documents)
Important: Failure to attach supporting documents shall cause the outright

dismissal of the complaint (NPC Circular 2021-01, Rule IV, Sec. 1).
1.
2.
3.
4.
5.

Page 5
RELIEFS PRAYED FOR: (Tick the box/es)

What would resolve this complaint for you?Minimum of one item must be
selected. You may also opt to select a combination of the items provided. Please
explain each item selected.
Damages Fine
Others, please describe

damage na po sa bupng pagkataplo dahil sa pgbabanta po.
I accomplished and reread the foregoing complaint and hereby attest

that all the allegations contained therein are true and correct of my own
personal knowledge and based on authentic records.
Complainant
(Signature over Printed Name)
Note: If the complainant wishes to apply for a temporary ban on processing

of personal data, a separate application should be filed. It must be verified
and shows facts entitling the complainant to the relief demanded.
SUBSCRIBED AND SWORN to before me on this day of

_________________, affiant exhibiting to me his/her __________________
I.D. with No. ____________________ issued on _______________ at
__________________ bearing his/her photo and signature.
Doc. No. _____;

Page No. _____;
Book No. _____;
Series of ______.

Page 6
VERIFICATION AND CERTIFICATION

OF NON-FORUM SHOPPING
I, ____________________________________, Filipino, of legal age, and

a resident of ______________________________________________ after
having duly sworn to in accordance with law, do hereby depose and state:
1. The allegations in the complaint are true and correct based on my

personal knowledge, or based on authentic documents;
2. The complaint is not filed to harass, cause unnecessary delay, or
needlessly increase the cost of litigation;
3. The factual allegations therein have evidentiary support or, if
specifically so identified, will likewise have evidentiary support after
a reasonable opportunity for discovery;
4. That I further certify that (a) I have not commenced any action or filed
any claim involving the same issues in any court, tribunal or quasi-
judicial agency and, to the best of my knowledge, no such other action
or claim is pending therein; (b) if there is such other pending action or
claim, a complete statement of the present status thereof; and (c) if I
should thereafter learn that the same or similar action or claim has
been filed or is pending, I shall report that fact within five (5) calendar
days therefrom to this Honorable Commission .
IN WITNESS WHEREOF, I have hereunto affixed my signature this

____ day of ___________ in __________________.
Affiant
(Signature over Printed Name)
SUBSCRIBED AND SWORN to before me on this day of

_________________, affiant exhibiting to me his/her __________________
I.D. with No. ____________________ issued on _______________ at
__________________ bearing his/her photo and signature.
Doc. No. _____;

Page No. _____;
Book No. _____;
Series of ______.


2023.09.01 Complaints Assisted Form 1 2

Uploaded by

Copyright:

Available Formats

2023.09.01 Complaints Assisted Form 1 2

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

2023.09.01 Complaints Assisted Form 1 2

Uploaded by

Copyright:

Available Formats

Republic of the Philippines

NATIONAL PRIVACY COMMISSION

COMPLAINTS AND INVESTIGATION DIVISION

REMINDERS: Complaints that are insufficient in form and in substance

1. Always fill out the Complaints-Assisted Form legibly, completely

PRIVACY NOTICE: We collect the following personal information from

USE: The collected personal information will be utilized solely for

PROTECTION MEASURES: Only authorized NPC personnel has access

NPC_LEO_CID_CAF-V4.0, R1.0, 01 September 2023

Lot/Block/Phase/House No. Street Name

ALLEGATIONS: Personal information that respondent has processed:

1. online loan app

NPC_LEO_CID_CAF-V4.0, R1.0, 01 September 2023

Contacted respondent, in writing, to allow respondent

Attach as supporting documents, any and all correspondence with the

Did not contact respondent. State reason:

VIOLATION SUBJECT OF COMPLAINT (Tick the box/es that may apply)

Sec. 25 Unauthorized Sec. 28. Processing for

Sec. 26. Access due to Sec. 31. Malicious

Sec. 27. Improper Disposal Sec. 32. Unauthorized

Date and Time of the Incident: 1pm-2am

Place of Incident: tawag lang po ng tWag wlaang tigil

NPC_LEO_CID_CAF-V4.0, R1.0, 01 September 2023

Narration of Facts: (Explain how the respondent committed a privacy violation)

Important: Failure to attach supporting documents shall cause the outright

NPC_LEO_CID_CAF-V4.0, R1.0, 01 September 2023

RELIEFS PRAYED FOR: (Tick the box/es)

Others, please describe

I accomplished and reread the foregoing complaint and hereby attest

Note: If the complainant wishes to apply for a temporary ban on processing

SUBSCRIBED AND SWORN to before me on this day of

Doc. No. _____;

NPC_LEO_CID_CAF-V4.0, R1.0, 01 September 2023

VERIFICATION AND CERTIFICATION

I, ____________________________________, Filipino, of legal age, and

1. The allegations in the complaint are true and correct based on my

IN WITNESS WHEREOF, I have hereunto affixed my signature this

SUBSCRIBED AND SWORN to before me on this day of

Doc. No. _____;

NPC_LEO_CID_CAF-V4.0, R1.0, 01 September 2023

You might also like