VAWC Form #4 CONTROL 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
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.

________________________________
Punong Barangay
(Signature over printed name)
Date issued: _____________________

Copy received by: ____________________________

(Signature over printed name)

Date received: _______________________________

Served by: __________________________________

ATTESTATION
(In case the Punong Barangay is not available)

hereby attest that Punong Barangay ________________________________________ was

unavailable to act on _________________________ at ____________ a.m./p.m. and issue such order.
(date) (time)

________________________________
Barangay Kagawad
(Signature over printed name)