Republic of the Philippines
Province of Occidental Mindoro
Municipality of Mamburao
Barangay Seven
Control NO. ______
TANGGAPAN NG PUNONG BARANGAY
APPLICATION FOR BARANGAY PROTECTION ORDER
1. Name of Applicant: _________________________________ Age: _____________
Address: _________________________________________ Cel #l:____________
Relationship to victim: _______________ Occupation:
2. Name of Victim: ___________________________________ Date of Birth: ______
3. Address: Brgy.____________________________________
Civil Status: Single Married Widow Separated Legal Separated
4. OCCUPATION/SOURCE OF INCOME:
5. NAMES OF CHILDREN DATE OF BIRTH SEX
1. _______________ _____________ _____
2. _______________ _____________ _____
6. NAME OF RESPONDENT: ____________________ Age: _____________
Occupation source of income: _______________
Address: Brgy. ____________________________________
7. Relationship of Complainant to Respondent:
Wife Former wife common law/live in relationship
8. Acts Complained of : (pls. check)
Threats Physical Injuries
9. Date of commission of the Offense: _______________________________________
10. Place where the offense was committed: ___________________________________
11. If the applicant is not the victim, state the circumstance of refusal to give consent of the
victim.
Signature of Applicant Over printed Name
Date: _______________________
VERIFICATION OF PUNONG BARANGAY
I hereby certify the applicant for BPO who appeared before me is a
bonafide resident of this Barangay and is the same person who supplied all the
above information and attest to the correctness ofsaid information.
Punong Barangay
Signature Over Printed Name
Control 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 witness, 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/or
her child/children namely:
1. __________________________
2. __________________________
This BPO is effective for 15 days from receipt.
VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW
Punong Barangay
Date issued: _____________
Copy received by: ____________________________
Signature over printed name
Date received by: _____________________________
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 _______________ on
______________ at ____________ am/pm and issued such order
(date) (time)
____________________________
Barangay Kagawad
Signature over printed name
Republic of the Philippines
Province of Occidental Mindoro
Municipality of Mamburao
Barangay Seven
TANGGAPAN NG PUNONG BARANGAY
VIOLENCE AGAINST WOMEN AND THEIR CHILDREN INCIDENT REPORT
I. PERSONAL CIRCUMSTANCES
a. Name of Complainant/Victims Age Address
________________________________ ________ _______________________
b. Civil Status c. Relationship to Perpetrator
Married Wife Girlfriend
Separated Ex-Wife Dating Relationship
Widow
II. INCIDENT DETAILS
a) Date/s of Violence Committed: __________________________
Date Reported: ____________________
b). Nature of Violence Infected by Perpetrator
Physical
Sexual
Psychological
Economic Abuse
III. ASSISTANCE EXTENDED/PROVIDED TO VICTIM/S
Specific Provided Remarks
Service Provided
Medical ________________ ________________ ___________
Counseling ________________ ________________ ___________
Medical ________________ ________________ ___________
Counseling ________________ ________________ ___________
Issued BPO: Date: __________________________
Prepared by:
Barangay Secretary
(Signature over printed name)
Date Accomplished: _____________________
Note: Please bring copy of this form to referral agency.
