DILG VAWC Form # 2

CTRL No. _______

REPUBLIC OF THE PHILIPPINES

PROVINCE OF SORSOGON
MUNICIPALITY OF IROSIN
BARANGAY BUENAVISTA

APPLICATION FOR BARANGAY PROTECTION ORDER

1. NAME OF APPLICANT: _______________________________________AGE:_____________

ADDRESS:________________________________________________TELL #______________
RELATIONSHIP TO VICTIM/S:_________________________OCCUPATION:____________
2. NAME OF VICTIM//S:_________________________________DATE OF BIRTH:__________
CIVIL STATUS: / / Single / / Married / / Widow / / Separated /
/ / Legally Separated / /
3. OOCUPATION/ SOURCE OF INCOME:____________________________________________
4. NAME/S OF CHILDREN DATE OF BIRTH SEX
____________________________ _______________________ ____________
____________________________ _______________________ ____________
____________________________ _______________________ ____________
____________________________ _______________________ ____________
____________________________ _______________________ ____________

4.a Other Children under her care

NAME DATE OF BIRTH SEX

___________________________ _______________________ ____________

___________________________ _______________________ ____________
___________________________ _______________________ ____________
___________________________ _______________________ ____________
___________________________ _______________________ ____________

5. NAME OF RESPONDENT:___________________________________AGE________________
OCCUPATION/SOURCE OF INCOME:_____________________________________________
ADDRESS_____________________________________________________________________
CIVIL STATUS: / / Single / / Married / / Widow / /
/ / Separated
6. Relationship of Complainant to Respondent:
/ / Wife / / Former Wife / / Common Law/ Live-in Relationship
/ / Dating Relationship / / Sexual Relationship
7. Acts Complained of (Pls. check)
/ / Threats / / Physical Injuries
8. Date of commission of the act
________________________________at________________________a.m/ p.m and such order.
(date) (time)
9. Place where the offense was committed
___________________________________________________________
10. If the applicant is not the victim, state the circumstances of refusal to give consent of the victim.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________

_______________________________________
Signature Of Applicant Over Printed Name

___________________________
Date

VERIFICATION OF PUNONG BARANGAY

I certify that the applicant for BPO who personally appeared before me is a
bonafide resident of this barangay and is the same person who applied all of the above
information and attest to the correctness of said information.

______________________________________
Punong Barangay
Signature Over Printed Name

Date Issued:
____________________
 DILG VAWC Form # 3
Bgy. Form no. _____
CTRL No. _______

REPUBLIC OF THE PHILIPPINES

PROVINCE OF SORSOGON
MUNICIPALITY OF IROSIN
BARANGAY BUENAVISTA

VIOLENCE AGAINST WOMEN AND THEIR CHILDREN INCIDENT

REPORT

I. PERSONAL CIRCUMTANCES
(A) Name of Complainant/ victim Age Address
__________________________ _________ ____________________________
__________________________ _________ ____________________________
__________________________ _________ ____________________________
__________________________ _________ ____________________________

(B) Civil Status (C) Relationship to Perpetrator

Married Wife Girlfriend

Separated Ex-Wife Dating Relationship
Widow

(C) Occupation/ Profession: Complainant Perpetrator

_______________________ ___________________________
II. INCIDENT DETAILS
(A) Date/s of Violence Committed

Date Reported ________________________________

(B) Nature of Violence Inflicted by Perpetrator

Physical ____________________________________________________________
Sexual _____________________________________________________________
Psychological ________________________________________________________
Economic Abuse _____________________________________________________
 III. ASSISTANCE EXTENDED/ PROVIDED TO VICTIMS
Specific
Services Provider Provided by: Remarks

Medical __________________________ ______________________

Counseling _________________________ _______________________
Refferal to __________________________ ______________________
Shelter ___________________________ ______________________
Issued BPO Date _________________________ ______________________

__________________________________ __________________________________
Date Accomplished (Signature Over Printed Name)
OFFICIAL ACCOMPLISHING THIS FORM

Note: Please bring copy of this form to referred agency