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Barangay Protection Order Application Form

This document is an application form for a Barangay Protection Order in the Philippines. It collects personal information about the applicant, victim, and respondent, including their relationships and details of the acts complained of. The form also includes a verification section for the Barangay official to confirm the applicant's identity and residency.

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eightythreebcogonsanjose
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9 views1 page

Barangay Protection Order Application Form

This document is an application form for a Barangay Protection Order in the Philippines. It collects personal information about the applicant, victim, and respondent, including their relationships and details of the acts complained of. The form also includes a verification section for the Barangay official to confirm the applicant's identity and residency.

Uploaded by

eightythreebcogonsanjose
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

VAWC FORM#3 CONTROL NO.

______

REPUBLIC OF THE PHILIPPINES


PROVINCE OF LEYTE
CITY OF TACLOBAN
BARANGAY______ ZONE _____ DISTRICT ____

APPLICATION FOR BARANGAY PROTECTION ORDER

1. NAME OF APPLICANT____________________________________ AGE: _______________


ADDRESS: _____________________________________________ TEL# _______________________
RELATIONSHIP TO VICTIM: _______________________________ OCCUPATION _______________
2. NAME OF VICTIMS: _____________________________________ DATE OF BIRTH: _____________
ADDRESS: _____________________________________________ TEL# _______________________
CIVIL STATUS Single Married Widow Seperated Legally Seperated
3. OCCUPATION/SOURCE OF INCOME: ___________________________________________________
4. NAME/S OF CHILDREN: DATE OF BIRTH: SEX:
_______________________ _____________ ______
_______________________ _____________ ______
_______________________ _____________ ______
_______________________ _____________ ______
4.a Other Children under her care
NAME/S OF CHILDREN: DATE OF BIRTH: SEX:
_______________________ _____________ ______
_______________________ _____________ ______
_______________________ _____________ ______
_______________________ _____________ ______
5. NAME OF RESPONDENT: ________________________________ AGE: ___________
OCCUPATION/SOURCE OF INCOME: ___________________________________________________
ADDRESS: _____________________________________________TEL#: _______________________
CIVIL STATUS Single Married Widow Seperated Legally Seperated
6. Relationship of Compliant to Respondent:
Wife Former Wifre Common Law/Live-in Relationship
Dating Relationship Sexual Relation ship
7. Acts Complained of (Pls. Check)
Treats Physical Injuries
8. Date of commission of the offense: ________________________________
9. Place where the offense was committed: ___________________________
10. If the applicant is not the victim, state the circumstances of refusal to give consent of the victim/

___________________________________
Signature of Appicant Over Printed Name
____________________
Date

VERIFICATION OF PUNONG BARANGAY

I certify that the applicant for BPO who personally appeared before me is a bonafinde resident of
this barangay and is the same person who supplied all the above information and attest to the correctness
of said information

__________________________
PUNONG BARANGAY

Date Issued: ___________________

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