VAWC Form #4CONTROL 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 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 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: __________________________________

ATTESTATION(In case the Punong Barangay is not available)

hereby attest that Punong Barangay ________________________________________ was unavailable to act on _________________________ at ____________ a.m./p.m. and issue such order. (date) (time)

________________________________ Barangay Kagawad (Signature over printed name)