Republic of the Philippines Province of Laguna Barangay_________ Office of the Barangay Captain

______________________________ Petitioner Brgy. Case No. _________________ Vs _____________________________ Respondent /.....................x For:__________________________

PETITION FOR THE ISSUANCE OF A BARANGAY PROTECTION ORDER (BPO)

COMES NOW, the petitioner, by ( ) a. the petitioner/offended party/complainant ( ) b. any member of the family or household of the offended party ( ) c. Social worker; ( ) d. Law enforcer who has personal knowledge of the abuses; ( ) e. Dept. of Social Welfare and Dev. (DSWD) and ( ) f. Accredited non-government organization (NGO).

Unto this Honorable Officer, respectfully avers: 1.That the Petitioner is of legal age, Filipino Citizen, married/live-in partner, and a resident of _________________________ 2.That the Petitioner is the (wife/husband, live-in partner, specific please) of the Respondent. 3.That the Respondent is the (husband/wife/live-in partner/any person) of the petitioner and they live together in the above mentioned address; 4.That on________,______ respondent has committed acts of against the person of the petitioner, more specifically described as follows: A.I. Physical violence consists of any or a combination of the following: ( )a.1. Slapping, pulling of hair, boxing, kicking, shoving, throwing, banging of the head on the floor, wall or any hard object or surface; ( )a.2. Hitting with an object or the use of deadly weapons; ( )a.3. Forcing the use or intake of alcohol, drugs or dangerous substances. A.II. The emotional/psychological forms of abuse include: ( ) a.1. Threats and intimidation including but not limited to stalking ( ) a.2. Verbal abuse such as shouting invectives against the victim; ( ) a.3. Name calling and derogatory remarks. (B) The economic or financial forms of abuse include ( ) b.1. Withholding of personal property or money due to the victim; ( ) b.2. Not contributing to the family budget;( ) b.3. Selling common or conjugal properly without the consent of the other party; ( ) b.4. Willful neglect or denial to provide support comprising everything indispensable for sustenance, dwelling, clothing, medical attendance, education and transportation in keeping with the financial capacity of the family. ( ) b.5. Unreasonably preventing the victim from engaging in any profession, occupation, business or activity, or solely controlling the victims own money or property;

5. That Respondent is (unemployed, working with, etc.) 6. That Respondent and Petitioner has (number of children, name of children, birth dates and age, if possible attach Birth Certificate) 7. That Petitioner could no longer bear the situation she/ he is suffering from the hands of respondent. 8. That the Petitioner would like to apply for a Barangay Protection Order (BPO) granted to her/him under Resolution No. 02-4177, Ordinance No. 1938, dated June 26, 2002. PRAYER WHEREFORE, premises considered it is respectfully requested from this Honorable Office to issue a BPO as prescribed under Ordinance No. 1938. That such BPO should include the following reliefs; ( ) a. Prohibit the respondent, personally or through another, from committing any act of domestic violence as defined herein; ( ) b. Order the respondent to immediately leave the domicile/residence of the petitioner; ( ) c. Prohibit the respondent from directly or indirectly communicating or contacting the petitioner; ( ) d. Grant custody of the minor children to the petitioners parent or such person or government agency to the best interest of such minor/s; ( ) e. Grant other reliefs as deemed necessary by this Honorable Office for the petitioners protection and for such other persons who may be in need of such protection.

_____________(date)__________, Sta. Cruz, Laguna

___________________________ Petitioner/Representative Res. Cer. No. ___________ Issued on ______________ Issued at_______________