VAWC FORM#4 CTRL.NO.

_______

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 issued
this BPO ordering you to immediately cease and desist from causing or threatening to cause physical harm
to _______________________________________________________________________________________
and for her child/children namely:
___________________________ ____________________________
___________________________ ____________________________
___________________________ ____________________________

This BPO is effective for 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: __________________________

Serve 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. _______ field by
_____________________________________
on _________________________ at ________________________a.m/p.m and issue such order
(date) (time)

________________________
VAWC FORM#4 CTRL.NO. _______

Barangay Kagawad
Signature over printed
name