Republic of the Philippines

Province of Cebu
MUNICIPALITY OF SIBONGA

BARANGAY GUIMBANGCO-AN

APPLICATION FOR BARANGAY PROTECTION ORDER

I __________________________________ under oath stating that :

_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

_____________________________________
Signature over printed name
of the complainant
 Republic of the Philippines
Province of Cebu
MUNICIPALITY OF SIBONGA

BARANGAY GUIMBANGCO-AN

Republic of the Philippines

Province of Cebu
MUNICIPALITY OF SIBONGA

BARANGAY GUIMBANGCO-AN
APPLICATION FOR BARANGAY PROTECTION ORDER

1. Name of Applicant: ______________________________________________

Age: __________
Address: _____________________________________________ Tel. No. ________
Relationship to the victim: ____________________________

2. Name of Victims: _________________________________

Date of Birth: ____________________________
Address: _________________________________
Civil Status : _______ single_____ married ____ widow _____ widower ______
Separated _____ legally separated ______

3. Occupation/ Source of income : ____________________

4. Name/ Names of children: Date of Birth: Sex:

______________________________ ___________________ ___________

______________________________ ___________________ ___________
______________________________ ___________________ ___________
______________________________ ___________________ ___________
______________________________ ___________________ ___________
______________________________ ___________________ ___________

Other children under her care:

______________________________
______________________________
______________________________
______________________________
______________________________
______________________________

5. Name of Respondent : _______________________________ Age: _________

Occupation : ___________________
Address: _______________________
 Civil Status : _______ single_____ married ____ widow _____ widower ______
Separated _____ legally separated ______

6. Relationship of the Complainant to the respondent:

_______ wife ________former wife ___________common law in relationship
_______dating relationship _______ sexual realationship

7. Acts Complained of (Pls. Check)

_______ Threats ________ Physical Injuries

8. Date of Commission of the Offense : __________________________

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 consent.

_____________________________________
Signature over printed name

_______________
Date:
_________________________________________________________________________________________________________

VERIFICATION OF THE PUNONG BARANGAY

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

ARSENIO D. VILLAVER
Punong Barangay
_______________
Date:
 Republic of the Philippines
Province of Cebu
MUNICIPALITY OF SIBONGA

BARANGAY GUIMBANGCO-AN
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 the evidence, the
undersigned hereby issues this BPO ordering you to immediately cease and desist from
causing or and/ or threatening to cause physical harm to
____________________________________
Complainant:
And /or her child/children hidden namely:
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________
________________________________________________

This BPO is effective for 15 days from receipt.

VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW.

ARSENIO D. VILLAVER
Punong Barangay
Date issued: ______________

Copy received by: _________________________________

Signature over printed name

Date received: _____________

Served by: _________________________________

Signature over printed name