ACTA DE ENTREVISTA AL IMPUTADO.doc

ACTA DE ENTREVISTA AL IMPUTADO / VICTIMA / TESTIGO INICIO: Lugar \ Día \ Mes \ Año y Hora:

I.

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DAT DATOS GENERA GENERALES LES

 Apellido paterno: ________________________, Apellido materno______________________  Nomre !s" _________________________________________________________________  Documento de identidad : DNI ____ LM _____ #asaporte _____ #artida de Na$imiento ____  Carn% de e&tran'ería _____ otros ______ N(__________________________  Sexo: M ______ ) _______  ec!a de Nacimiento "d/m/a#: $$$$$$$$$/$$$$$$$$$/$$$$$$$$$$$Edad:$$$$$$$$$$$$$$  Lu%a& de Nacimiento: Pa'($$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ D)to. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$* P&o+. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  Ciudad$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  Di(t&ito$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  E(tado Ci+i,: Ca(ado $$$$ Di+o&ciado $$$$  Di+o&ciado $$$$ Con+i+iente $$$$  Con+i+iente $$$ So,te&o $$$  So,te&o $$$ Se)a&ado $$$  Se)a&ado $$$$  Ot&o( $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  Ni+e, de In(t&ucci-n$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  Di&ecci-n Domici,ia&ia ________________________________________________________   $$$$$$$$$$$$$$  $$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$ $$$$$$$$$$$$$ $$$$$$$$$$$$$$ $$$$$$$$$$$$$$ $$$$$$$$$$$$$$ $$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$ $$$$$$$$$$$$  $$$$$  Di&ecci-n de Notiicacion$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$   $$$$$$$$$$$$$$  $$$$$$$$$$$$$$$$$$$$$ $$$$$$$$$$$$$ $$$$$$$$$$$$$ $$$$$$$$$$$$$$ $$$$$$$$$$$$$$ $$$$$$$$$$$$$$ $$$$$$$$$$$$$$$ $$$$$$$$$$$$$$$ $$$$$$$$$$$$  $$$$$  Te,ono de Contacto $$$$$$$$$$$$$$$* Co&&eo E,ect&-nico$$$$$$$$$$$$$$$$$$$$$$$$ 

#ro*esi+n__________________________________O$upa$i+n________________________  ela$i+n $on la -í$tima: .i _____ No ______  Con el !la" denun$iante .i _____ No _____  Con el !la" denun$iado !a" .i ______ No ______  /spe$i*i0ue_________________________________________________________________   ______________________________________________________________ _____________  Cara$terísti$as *ísi$as: !Des$riir" _______________________________________________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________  II.

RELATO RELATO DE LOS LOS 0EC0OS: 0EC0OS: ")a&tici)")a&tici)- 1 )&e(enci)&e(enci- 1 conoci-#

 ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________ 

 ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________  .e le in*ormo 0ue se utili1+ medios t%$ni$os para el registro de la entre-ista .I _____ NO _______  Lugar \ Año \ Mes \ Día y Hora: _____________________________________________________  )irma _________________________________________  ______________________________________________  DNI2 Nro2 ______________________________________ 

#/.ONAL #N#

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/L /#/./N3AN3/ D/L MINI.3/IO #45LICO _____________________________ 

ACTA DE ENTREVISTA AL IMPUTADO / VICTIMA / TESTIGO INICIO: Lugar \ Día \ Mes \ Año y Hora: _______________________________________________  III.

DATOS GENERALES

 Apellido paterno: ________________________, Apellido materno______________________  Nomre !s" _________________________________________________________________  Documento de identidad : DNI ____ LM _____ #asaporte _____ #artida de Na$imiento ____  Carn% de e&tran'ería _____ otros ______ N(__________________________  Sexo: M ______ ) _______  ec!a de Nacimiento "d/m/a#: $$$$$$$$$/$$$$$$$$$/$$$$$$$$$$$Edad:$$$$$$$$$$$$$$  Lu%a& de Nacimiento: Pa'($$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$ D)to. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$* P&o+. $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  Ciudad$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  Di(t&ito$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  E(tado Ci+i,: Ca(ado $$$$ Di+o&ciado $$$$ Con+i+iente $$$ So,te&o $$$ Se)a&ado $$$$  Ot&o( $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  Ni+e, de In(t&ucci-n$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  Di&ecci-n Domici,ia&ia ________________________________________________________   $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  Di&ecci-n de Notiicacion$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$   $$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$  Te,ono de Contacto $$$$$$$$$$$$$$$* Co&&eo E,ect&-nico$$$$$$$$$$$$$$$$$$$$$$$$ 

#ro*esi+n__________________________________O$upa$i+n________________________  ela$i+n $on la -í$tima: .i _____ No ______  Con el !la" denun$iante .i _____ No _____  Con el !la" denun$iado !a" .i ______ No ______  /spe$i*i0ue_________________________________________________________________   ______________________________________________________________ _____________  Cara$terísti$as *ísi$as: !Des$riir"  ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________  IV. RELATO DE LOS 0EC0OS: ")a&tici)- 1 )&e(enci- 1 conoci-#

 ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________  C-di%o 2nico de ca&)eta i(ca,

P&io&idad Di(t&ito 3udicia,

Ministerio #6li$o )is$alía de la Na$i+n  ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________   ______________________________________________________________ _____________  .e le in*ormo 0ue se utili1+ medios t%$ni$os para el registro de la entre-ista .I _____ NO _______  Lugar \ Año \ Mes \ Día y Hora:  ______________________________________________________  )irma ___________________________________  ___________________________________________  DNI2 Nro2 ___________________________________ 

)irma !." _________________________________ CI# ___________________  Cargo: _________________________