Republic of the Philippines

Province of Sorsogon
Municipality of Irosin
Barangay Buenavista

BARANGAY PROTECTION ORDER

NAME OF RESPONDENT:__________________________
ADDRESS:_______________________________________

ORDER:
______________________________ applied for a BPO on ___________________,
under oath stating that:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
.
After having 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 for 15 days from receipt.
VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW.

Signature over printed name of Punong Baranagy

Date Issued:_______________
Copy received by:__________________________
Date received:_____________________________
Serve by:________________________________
Signature over printed named
ATTESTATION
(In case the Punong Barangay is unavailable)
I hereby attest that the Punong Barangay ____________________ was
unavailable to act on Application for Barangay Protection Order No. ____ filed by
______________________ on ___________________at ________a.m/p.m and issue
such order.
Signature over printed name of Punong Barangay