VAWC Form # 4

VAWC Form # 4 CTRL 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
issued this BPO ordering you to immediately cease and desist from causing and threatening to cause
physical harm to
And /or her child/children;

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:
Signature over printed name

ATTESTATION
(In case the Punong Barangay is unavailable)

I hereby attest that Punong Barangay was unavailable act

on Application for Barangay Protection Order No. filed by
On at am/pm and issue such order.

Punong Barangay
Signature over printed name