Republic of the Philippines

NATIONAL PRIVACY COMMISSION

COMPLAINTS-ASSISTED FORM

By filling out this complaint form, you hereby sworn that you are the
complainant and you will have to appear in the office for oath taking. Willful
and deliberate assertion of falsehood will be criminally prosecuted. List of
accepted government issued ID’s:

• Philippine Passport
• Philippine Driver’s License
• PRC ID
• Postal ID
• Voter’s ID
• GSIS Card
• SSS Card
• TIN Card
• Student ID

Answer the following questions. Do not leave any field blank.

Do you have a concern about a privacy violation, personal data breach or

matters related to personal data protection, or any other violation of the Data
Privacy Act, its IRR and other issuances?

YES. Proceed to the next section.

If NO, do not proceed. The National Privacy Commission may

have no power to act on your complaint. The Commission can
only act on matters that relate to Data Privacy.

Does your concern affect you personally or it involves your personal data?

YES. Proceed.

NO.
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Page 2 of 8

Have you contacted the agency/individual you are about to complain?

YES. Please attach proof.

NO. Please explain.

Complainant’s Personal Information

First Name

Middle Initial

Last Name

Valid ID

ID Number

Present Address

*Please indicate complete

address, including zip
code, for mailing of orders
and other issuances of this
Commission

Permanent Address

*Please indicate complete

address, including zip
code, for mailing of orders
and other issuances of this
Commission

Email Address

Contact Number
 Complaints-Assisted Form
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Respondent's Information (Party Complained Against)

Name

Present Address
*Please indicate complete
address, including zip
code, for mailing of orders
and other issuances of this
Commission

Contact Number

Website (if any)

Complaint

Describe the
complaint

*Please write legibly

Please select the provision

violated by the
respondent:

Section 25
Unauthorized Processing
of Personal Information
and Sensitive Personal
Information

Section 26
Accessing Personal
Information and Sensitive
Personal Information Due
to Negligence

Section 27
Improper Disposal of
Personal Information and
Sensitive Personal
Information

Section 28
Processing of Personal
Information and Sensitive
Personal Information for
Unauthorized Purposes

Section 29
Unauthorized Access or
Intentional Breach
 Complaints-Assisted Form
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.
Continuation

*Please write legibly

Please select the provision

violated by the
respondent:

Section 30
Concealment of Security
Breaches Involving
Sensitive Personal
Information

Section 31
Malicious Disclosure

Section 32
Unauthorized Disclosure

Section 33
Combination or a Series
of Acts

Section 35
Large-Scale

Section 36
Offense Committed by a
Public Officer
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.
What personal
information
about you was
affected?

Date of the
incident

Time of the
incident

Place of the
incident

Do you know Yes ______ No ______

who did it?

How and when

did you find
out about it?
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How have you

been affected?

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.

A. Settlement

B. Damages

C. Fine
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D. Advisory
Opinion

E. Cease and
Desist Order

F. Others

Are you seeking an Order to temporarily or permanently stop the processing

of your data? (This requires a summary hearing.)

YES. On what grounds

NO.
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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)

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 20___.