Republic of the Philippines

Province of Catanduanes
Municipality of ________________
Barangay ______________

APPLICATION FOR BARANGAY PROTECTION ORDER

1. NAME OF APPLICANT: _______________________________AGE: ________

ADDRESS: _________________________________________TEL/CP #: ______________________
RELATIONSHIP TO VICTIM: ___________________________ OCCUPATION: __________________

2. NAME OF VICTIM: __________________________________ DATE OF BIRTH:

ADDRESS: _________________________________________TEL/CP #: ______________________
CIVIL STATUS: SINGLE MARRIED WIDOW SEPARATED LEGALLY SEPARATED

3. OCCUPATION/SOURCE OF INCOME: ____________________

4. NAME OF CHILDREN: DATE OF BIRTH SEX
___________________________ ______________________ _______
___________________________ ______________________ _______
___________________________ ______________________ _______
___________________________ ______________________ _______
___________________________ ______________________ _______
4.A Other Children under her care
NAME OF CHILDREN: DATE OF BIRTH SEX
___________________________ ______________________ _______
___________________________ ______________________ _______
___________________________ ______________________ _______
___________________________ ______________________ _______
5. NAME OF RESPONDENT: _____________________________ AGE: _______
ADDRESS: _________________________________________TEL/CP #: ______________________
CIVIL STATUS: SINGLE MARRIED WIDOW SEPARATED LEGALLY SEPARATED

6. Relationship of Complainant to Respondent:

Wife Common Law/Live-in Relationship
Dating Relationship Sexual Relationship
Former Wife

7. Acts Complained of: (please Check)

Threats Physical Injuries

8. Date of Commission of Offense: _______________________

9. Place where the offense was committed: ________________
10. If the applicant is not a victim, state the circumstance of refusal to give consent of the victim.

______________________________________
Signature of the Applicant over Printed Name
___________________
Date
___________________________________________________________________________________________
VERIFICATION OF PUNONG BARANGAY

I certify that the application for BPO who personally appeared before me is a bonafide resident of this
barangay and is the same person who supplied all the above information and attest to the correction of said
information.
________________________________
Punong Barangay
Signature over Printed Name
Date Issued: ____________________
 BARANGAY PROTECTION ORDER

NAME OF RESPONDENT: ___________________________________________

ADDRESS: _______________________________________________________

ORDER

_________________________________________applied for a BPO on ________________________ under

oath stating that ____________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________

After having heard the application and the witnesses and evidence, the undersigned hereby
issues this BPO ordering you to immediately cease and desist from causing or threatening to cause
physical harm to _________________________________and/or her child/children namely:
__________________________________ _______________________________
__________________________________ _______________________________
__________________________________ _______________________________

This BPO is effective 15 days from receipt.

VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW.

_______________________________
Punong Barangay
Signature over Printed Name
Date Issued: ___________________

Copy Received by: ____________________________

Signature over Printed Name
Date Received: ____________________________

Served by: ____________________________

Signature over Printed Name

ATTESTATION
(In case the Punong Barangay is unavailable)

I hereby attest that Punong Barangay _______________________________ was unavailable to act on

Application for Barangay Protection Order No. ______ filed by _________________________________
on ___________________ at _________ am/pm and issue such order.

_______________________________
Barangay Kagawad
Signature over Printed Name