Fillable COMPLAINTS-ASSISTED FORM (gov)

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COMPLAINTS-ASSISTED FORM (gov)

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Republic of the Philippines
NATIONAL PRIVACY COMMISSION
Ref No.: _____________ NPC_LEO_CID_CAF-V1.0, R0.0, 05 April 2021
5
th
Floor, Philippine International Convention Center, Vicente Sotto Avenue, Pasay City, Metro Manila 1308
URL: https//www.privacy.gov.ph Email Add: info@privacy.gov.ph Tel No. 8234-2228
Complaints and Investigation Division
RECEIVED BY:
Name: _________________________
Date and Time: __________________
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
• Philippine Driver’s License
• PRC ID
• Postal ID
• Voter’s ID
• GSIS Card
• SSS Card
• 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
- 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.
Page 2 of 6
Ref No.: _____________ NPC_LEO_CID_CAF-V1.0, R0.0, 05 April 2021
5
th
Floor, Philippine International Convention Center, Vicente Sotto Avenue, Pasay City, Metro Manila 1308
URL: https//www.privacy.gov.ph Email Add: info@privacy.gov.ph Tel No. 8234-2228
COMPLAINANT INFORMATION
Name:
Address:
E-mail address:
Contact number:
Female
Male
RESPONDENT INFORMATION
Name:
Address:
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.
2.
3.
4.
5.
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.
Page 3 of 6
Ref No.: _____________ NPC_LEO_CID_CAF-V1.0, R0.0, 05 April 2021
5
th
Floor, Philippine International Convention Center, Vicente Sotto Avenue, Pasay City, Metro Manila 1308
URL: https//www.privacy.gov.ph Email Add: info@privacy.gov.ph Tel No. 8234-2228
3.
4.
5.
Did not contact respondent.
Reason for not contacting respondent.
VIOLATION SUBJECT OF COMPLAINT (Tick the box/es that may apply)
Sec. 25 Unauthorized Processing
Sec. 28. Processing for Unauthorized Purposes
Sec. 26. Access due to Negligence
Sec. 31. Malicious Disclosure
Sec. 27. Improper Disposal
Sec. 32. Unauthorized Disclosure
Date and Time of the Incident:
Place of Incident:
Narration of Facts: (Explain how the respondent committed a privacy violation)
Page 4 of 6
Ref No.: _____________ NPC_LEO_CID_CAF-V1.0, R0.0, 05 April 2021
5
th
Floor, Philippine International Convention Center, Vicente Sotto Avenue, Pasay City, Metro Manila 1308
URL: https//www.privacy.gov.ph Email Add: info@privacy.gov.ph Tel No. 8234-2228
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.
Page 5 of 6
Ref No.: _____________ NPC_LEO_CID_CAF-V1.0, R0.0, 05 April 2021
5
th
Floor, Philippine International Convention Center, Vicente Sotto Avenue, Pasay City, Metro Manila 1308
URL: https//www.privacy.gov.ph Email Add: info@privacy.gov.ph Tel No. 8234-2228
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.
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 2021.
Page 6 of 6
Ref No.: _____________ NPC_LEO_CID_CAF-V1.0, R0.0, 05 April 2021
5
th
Floor, Philippine International Convention Center, Vicente Sotto Avenue, Pasay City, Metro Manila 1308
URL: https//www.privacy.gov.ph Email Add: info@privacy.gov.ph Tel No. 8234-2228
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 2021.
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COMPLAINTS-ASSISTED FORM (gov)

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Completed 28 May 2021

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