REPUBLIC OF THE PHILIPPINES

PROVINCE OF PAMPANGA
MUNICIPALITY OF GUAGUA
BARANGAY STO.NIÑO

VAWC Form #3 CTRL No._____________

APPLICATION FOR BARANGAY PROTECTION ORDER

1. NAME OF APPLICANT: ______________________________ AGE: _________________

ADDRESS: __________________________________________ CONTACT #: __________________
RELATIONSHIP TO VICTIM:__________________________ OCCUPATION: ________________
2. NAME OF VICTIMS: _________________________________ DATE OF BIRTH: ______________
ADDRESS: _________________________________________ CONTACT #: __________________
CIVIL STATUS: SINGLE MARRIED WIDOW SEPARATED LEGALLY SEPARATED
3. OCCUPATIONS/SOURCE OF INCOME: _________________________________________________
4. NAMES 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: __________________________________________ CONTACT #: __________________
CIVIL STATUS: SINGLE MARRIED WIDOW SEPARATED LEGALLY SEPARATED
6. Relationship of Complainant to Respondent:
Wife Former Wife Common Law/Live-in Relationship
Dating Relationship Sexual Relationship
7. Acts Complained of:
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 circumstance of refusal to give consent of the victim.

__________________________________
Signature of Applicant Over Printed Name
___________________________________________________________________________________________
VERIFICATION OF PUNONG BARANGAY
I certify that the applicant for BPO who personally appeared before me is a bona fide resident of this barangay
and is the same person who supplied all the above information and attest to the correctness of said information.

___________________________________
Punong Barangay
Date: _____________________