VAWC FORM#4 CTRLNO.

________

BARANGAY PROTECTION ORDER

NAME OF RESPONDENT: __________________________________

ADDRESS: __________________________________________________

ORDER
_________________________________applied for a BPO on _______________, under oath stating
That:
________________________________________________________________________________________
________________________________________________________________________________________

________________________________________________________________________________________

After having heard the application and the withnesses and evidence, the undersigned hereby issued
this BPO ordering you to immediately cease and desist from causing or threatening to cause physical harm
to ______________________________________________________________________________________
and for her child/children namely:
__________________________ _________________________
__________________________ _________________________
__________________________ _________________________

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: _________________________

Serve by: __________________________

Signature over printed name

ATTESTATION
( In case the Barangay is unavailable)

I hereby attest that Punong Barangay _______________________________ was unavailable to act on

Application for Barangay Protection Order No. ________ field by
________________________________
On _______________________ at _____________________a.m/p.m and issue such order
(date) (time)

___________________________