Control No.

__________

BARANGAY PROTECTION ORDER

Name of Respondent: _________________________________________

Address: _________________________________________________________________
_________________________________________________________________

ORDER

_______________________________________ applied for a Barangay Protection Order (BPO) on

____________________, under oath stating that:
(Date and time)

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

After having heard the application and the witnesses and evidence, the undersigned herein 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: ____________________________

Signature over printed name
 ATTESTATION
(in case the Punong Barangay is unavailable)

I hereby attest that Punong Barangay ________________________________ was unavailable to

act on Application for Barangay Protection Order No. __________________ filed by
__________________________________________ on _______________________________ at
______________________ A.M. / P.M. and issue such order.

________________________________
Barangay Kagawad
Signature over printed name