REPUBLIC OF THE PHILIPPINES

OFFICE OF THE SANGGUNIANG BARANGAY

BARANGAY 630 ZONE 63, DISTRICT VI
Anonas St. Sta Mesa, Manila
Tel No. 82431139
Email Address: elbravura03@gmail.com / brgy630@gmail.com
__________________________________________________________________________________

APPLICATION FOR BARANGAY PROTECTION ORDER

1. NAME OF APPLICANT: _______________________________ DATE OF BIRTH: ____________

ADDRESS: ____________________________________ TEL NO.: _______________________
RELATIONSHIP TO VICTIM/S: ___________________________ OCCUPATION: ____________
2. NAME OF VICTIM/S: __________________________ DATE/S OF BIRTH: _________________
ADDRESS: ____________________________________ TEL NO.: _______________________
OCCUPATION/SOURCE OF INCOME: ______________________
CIVIL STATUS: ___ Single ___ Married ___ Widow ___ Separated ___ Legally Separated
NAME/S OF CHILDREN: DATE/S OF BIRTH: SEX:
__________________________ ___________________ _________
__________________________ ___________________ _________
__________________________ ___________________ _________
__________________________ ___________________ _________
3. OTHER CHILDREN UNDER HER CARE: DATE/S OF BIRTH SEX:
______________________________ ______________ ____
______________________________ ______________ ____
4. NAME OF RESPONDENT: _____________________________ DATE OF BIRTH: ____________
ADDRESS: _____________________________________ TEL NO.: ______________________
SEX: ______ OCCUPATION/SOURCE OF INCOME: ___________________________
CIVIL STATUS: ___ Single ___ Married ___ Widow ___ Separated ___ Legally Separated
5. RELATIONSHIP OF VICTIM TO RESPONDENT: ____ Wife ____ Former Wife ____ Live-in Relationship ____
Dating Relationship ____ Sexual Relationship
6. ACTS COMPLAINED OF: ____ Threats ____ Physical Injuries
DESCRIPTION: _______________________________________________________________
___________________________________________________________________________
7. DATE/S OF COMMISSION: _______________________
8. PLACE/S OF COMMISSION: ________________________________________________
9. If applicant is not the victim, state the circumstances of consent:
__________________________________________________________________________________________
____________________________________________________________

Applicant: __________________________ Date: ____________________

_____________________________
Signature Over Printed Name

VERIFICATION OF THE PUNONG BARANGAY

I hereby certify that the applicant 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 correctness of said
information.

CRISTINA F. LARA
Punong Barangay
Signature Over Printed Name
 REPUBLIC OF THE PHILIPPINES
OFFICE OF THE SANGGUNIANG BARANGAY
BARANGAY 630 ZONE 63, DISTRICT VI
Anonas St. Sta Mesa, Manila
Tel No. 82431139
Email Address: elbravura03@gmail.com / brgy630@gmail.com
__________________________________________________________________________________

BARANGAY PROTECTION ORDER

NAME OF RESPONDENT: TEODERICO DELA CRUZ

ADDRESS: 1-118 MAUI OASIS CONDOMINIUM, ANONAS ST., STA MESA, MANILA

ORDER

MARIBEL GUTIERREZ TACDOL applied for a BPO on December 03, 2021, under oath stating that:

Based on the statement of the deponent on her complaint, the abovementioned respondent,
accused her of talking to someone on the phone, and told her “pokpok”, and told her to that she couldn’t
take the child “their adopted daughter” and house “unit which where they lived together”. And according
also to the deponent the respondent pointed her on her forehead, cursed and threatened her.

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 MARIBEL GUTIERREZ TACDOL and/or her child/children namely:

PATRICIA ADEL DELA CRUZ _______________________________________

________________________________________ _______________________________________
________________________________________ _______________________________________

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)

________________________________
 REPUBLIC OF THE PHILIPPINES
OFFICE OF THE SANGGUNIANG BARANGAY
BARANGAY 630 ZONE 63, DISTRICT VI
Anonas St. Sta Mesa, Manila
Tel No. 82431139
Email Address: elbravura03@gmail.com / brgy630@gmail.com
__________________________________________________________________________________

Barangay Kagawad
(Signature over printed name)

accused of talking on a cellphone, which according

to ms. tacdol had no one to talk to on the cellphone,
and told him it was a "pokpok" and told him he
couldn't take the child "their son" and the house. he
allegedly stabbed her and threatened to hurt her.