VAWC FORM # 3

CTRL NO. __
REPUBLIC OF THE PHILIPPINES
PROVINCE OF ________________
MUNICIPALITY OF ________________
BARANGAY ________________
APPLICATION FOR BARANGAY PROTECTION ORDER

1.
2.

NAME OF APPLICANT: _______________________________________ AGE: _______

ADDRESS: _________________________________________________ TEL. NO.: _______________________
RELATIONSHIP TO VICTIM: ___________________________________ OCCUPATION: ___________________
NAME OF VICTIM: ___________________________________________ DATE OF BIRTH: __________________
ADDRESS: _________________________________________________ TEL. NO.: _______________________
CIVIL STATUS: Single Married Widow Separated Legally Separated

3.

OCCUPATION/SOURCE OF INCOME: ______________________________________________________

4.

NAME/S OF CHILDREN
___________________________
___________________________
___________________________
___________________________
___________________________
4a. Other children under her care
NAME/S OF CHILDREN
___________________________
___________________________
___________________________
___________________________
___________________________

5.

DATE OF BIRTH
______________________
______________________
______________________
______________________
______________________

SEX
___________
___________
___________
___________
___________

DATE OF BIRTH
______________________
______________________
______________________
______________________
______________________

SEX
___________
___________
___________
___________
___________

6.

NAME OF RESPONDENT: ______________________________________ AGE: _______

OCCUPATION/SOURCE OF INCOME: ______________________________________________________
ADDRESS: _________________________________________________ TEL. NO.: _______________________
CIVIL STATUS: Single
Married
Widow
Separated

7.

Relationship of Complainant to Respondent:

Wife
Former Wife
Common Law/Live in Relationship
Dating Relationship
Sexual Relationship

8.

Acts Complained of: (Please 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 certify that the applicant for BPO who personally appeared before me is a bona fide 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
Signature of Applicant over Printed Name
Date Issued: ______________