Republic of the Philippines

Province of Cavite
City of Bacoor
Barangay Aniban II

VAWC Form No. 4 Control No.: ___________________

BARANGAY PROTECTION ORDER

NAME OF RESPONDENT: _________________________________________________________

ADDRESS: ______________________________________________________________________

ORDER
_________________________________________ applied for a B.P.O on __________________. Under oath stating that:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
After having heard the application and the witnesses and evidence, the undersigned hereby issues this B.P.O ordering you
to immediately cease and desist from causing or threatening to cause physical harm to
_______________________________________ and/or her child/children namely;

___________________________________ __________________________________
___________________________________ __________________________________
___________________________________ __________________________________

This Barangay Protection Order is effective for fifteen (15) days from receipt.

VIOLATIONS OF THIS ORDER IS PUNISHABLE BY LAW

________________________
RAUL E. ENRIQUEZ, Jr.
Punong Barangay

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 Raul E. Enriquez, Jr. was unavailable to action Application for Barangay
Protection Order No. __________ filed by __________________________________ on ____________________ at
_______________ a.m. /p.m. And issue such order.

__________________________
Barangay Kagawad
Signature over printed Name