IP

Republic of the Philippines

Province of Zamboanga Sibugay
* * Municipality of Ipil
BARANGAY IPIL HEIGHTS
A
-oOo-

OFFICE OF THE PUNONG BARANGAY

VAWC Form #4 CTRL NO.________

BARANGAY PROTECTION ORDER

NAME OF RESPONDENT: ____________________________________

ADDRESS: _________________________________________________

ORDER

_______________________applied for 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 15 days from receipt.

VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW

IRIC MANGUBAT ALIBUTDAN

Punong Barangay
Signature Over Printed Name

Date Issued:
___________________

Copy received by: ____________________________

Signature Over Printed Name

Date received: _____________________

Served by: ________________________

Signature Over Printed Name

ATTESTATION
I hereby attest that Punong Barangay _______________________________ was unavailable to
act
On application for Barangay Protection Order No. ________ filed by
_______________________________
On __________________ at __________________ a.m/ p.m and issue such order.

HON. RODERICK P.
EPANTO Barangay
Kagawad
Signature Over Printed Name

Official seal of Barangay Ipil Heights

(Not valid without Dry Seal)

Note: Corrections and alterations made to this document

automatically voids its function.