Republic of the Philippines

Province of Tarlac
City of Tarlac
Barangay SAN ISIDRO

Office of the Punong-Barangay

DILG VAWC Form # 1
Ctrl. No. ____
BARANGAY PROTECTION ORDER

NAME OF RESPONDENT : ____________________________________

ADDRESS : Zone ____ Barangay ______________________, ___________________

ORDER

Mrs. ___________________________________ applied for a Barangay Protection Order (BPO) at ____

:00 am/pm under oath __________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
After having heard the application and the witness and evidence , the undersigned
hereby this BPO ordering you to immediately cease and desist oF threathening to cause
___________________________ harm to :
Mrs. __________________________________________ and / or her child / children namely :
1. _________________________________________ - _____ years old
2. _________________________________________- _______ years old
3. __________________________________________- _______ years old
4. _________________________________________ - ________ years old

Thgis BPO is effective for 15 days from receipt.

VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW

Hon. Gloria T. Buhay

Punong- Barangay

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 the Punong- Barangay was unavailable to act on Application for
Barangay Protection Order No. ____ filed by Mrs. ____________________________________ on
_________________.

Republic of the Philippines

Province of Tarlac
City of Tarlac
Barangay SAN ISIDRO

Office of the Punong-Barangay

APPLICATION FOR BARANGAY PROTECTION ORDER

1. Name of Applicant : _________________________________________________

Age : ________
Address : _________________________________________________
Cel No. ________________________________________________

2. Name of Victims : ______________________________________Birthday : ___________________

Name :
_______________________________________________________________________
Name :
_______________________________________________________________________
Name :
_______________________________________________________________________
3. Occup[ation / Source of Income : _______________
4. Name of Children :
Date of Birth
Sex
______________________________________________________
______________________________________________________
_____________________________________________________
_____________________________________________________

5. Name of Respondent : ________________________________________________ Age : ____

Occupation : _____________________
Address : ______________________________________________________________
Civil Status : _________________

6. Relationship of Complainant to respondent : ____________________________

7. Acts Complained :

( _) Threats (__) Physical Injuries

Others : ________________________________
 Republic of the Philippines
Province of Tarlac
City of Tarlac
Barangay SAN ISIDRO

Office of the Punong-Barangay

DILG VAWC FORM # ____

Brgy Form No. ______
Ctrl. No. _______

VIOLATION AGAINST WOMEN AND THEIR CHILDREN INCIDENT REPORT

1. PERSONAL CIRCUMSTANCES

Name of Complainant Age Address

___________________________________ _________
______________________________
___________________________________ _________
______________________________
___________________________________ _________
______________________________
___________________________________
\ _________
______________________________
___________________________________ _________
______________________________

Complainant Perpetrator

________________________ ___________________

2. Incident Details
(a) Date/ s of Violence Committed
_____________________________________
(b) Nature of Violence Inflicted by Perpetrator

(__) Physical Abuse

(__) Sexual Abuse
 (__) Psycological Abuse
(__) Economic Abuse

3. Assistance Extended / Provided toVictims

(__) Specific __________________

(__) Counselling __________________
(__) Refferal to __________________
(__) Shelter _________________

Issued BPO Date : ___________________________

___________________________