VAWC Form

CTRL
#4
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 for fifteen (15) days from receipt.

VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW

___________
___________
__
Punong
Copy Barangay
received by: Signature
___________
___________
______
ATTESTATION
( In case the Punong Barangay is unavailable)
I hereby attest that Punong Barangay __________________________ was unavailable to action Application for
Barangay Protection Order No. _______ filed by __________________________________ on _______________ at
________
AM/PM and issued such order. ( date ) ( time )
___________
___________
__
Barangay
Kagawad
Signature