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)