This document is an acta from the Juan XXIII Educational Center in Pereira, Colombia. It details a case presented by a student regarding serious or very serious offenses. The student's name, grade, and description of the events are recorded. The declarant signs at the bottom to confirm the report.

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CENTRO EDUCATIVO JUAN XXIII
Aprobado por la Secretaria de Educación Municipal Según Resolución Nº 6128 del 30 de octubre de 2013
NIT: 900.006.917-0 DANE 166001000301
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Nunca consideres el estudio como una obligación, sino como una oportunidad para penetrar en el bello y
maravilloso mundo del saber. Albert Einstein
Cra. 23 Bis Nro. 74 - 40 Comuna Cuba -Tel: 3372911 e-mailjuan23pereira@gmail.com www.rectoriajuan23pereira.blogspot.com
ACTA (ALUMNO QUEJOSO Y/O TESTIGOS) DE DECLARANTE PARA FALTAS
GRAVES Y GRAVÍSIMAS
FECHA: _______________________________________________________________________
ESTUDIANTE: _______________________________________________________________________
GRADO: _______________________________________________________________________
CASO PRESENTADO: _______________________________________________________________________
Descripción de los hechos:
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Firma del Declarante: ______________________________________________________________
De requerirlo continúe atrás y firme nuevamente al final del informe.