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Vawc Form #3 Application For BPO

This document is an application for a Barangay Protection Order (BPO) filed with the local government of Tarangnan, Samar in the Philippines. It collects information about the applicant, victim, respondent, and details of the offense to determine if a BPO should be issued. Specifically, it requests the names, addresses, relationships and other details about the applicant, victim and respondent. It also asks the applicant to specify the acts complained of, date of offense, location and relationship between the applicant and respondent. The punong barangay verifies the applicant's identity and residence before the application is considered.

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Joy Toledo Enarsico
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550 views1 page

Vawc Form #3 Application For BPO

This document is an application for a Barangay Protection Order (BPO) filed with the local government of Tarangnan, Samar in the Philippines. It collects information about the applicant, victim, respondent, and details of the offense to determine if a BPO should be issued. Specifically, it requests the names, addresses, relationships and other details about the applicant, victim and respondent. It also asks the applicant to specify the acts complained of, date of offense, location and relationship between the applicant and respondent. The punong barangay verifies the applicant's identity and residence before the application is considered.

Uploaded by

Joy Toledo Enarsico
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
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VAWC FORM/ # 3

VAWC FORM # 3 CTRL NO. _____________

REPUBLIC OF THE PHILIPPINES


PROVINCE OF SAMAR
CITY/MUNICIPALITY ___TARANGNAN___
BARANGAY ________________________

APPLICATION FOR BARANGAY PROTECTION ORDER

1. NAME OF APPLICANT: ___________________________________________________ AGE _________________


ADDRESS: _____________________________________________________________CP# __________________
RELATIONSHIP TO VICTIM; ____________________________ OCCUPATION: ____________________________
2. NAME OF VICTIM/S ___________________________________DATE OF BIRTH: __________________________
ADDRESS: _______________________________________________ CP# ________________________________
CIVIL STATUS: _____ Single _____ Married ____Widower ______ Separated ______Legally Separated_____Common Law Wife ___
3. OCCUPATION/ SOURCE OF INCOME: ______________________________________________________________

4. NAME/S OF CHILDREN: DATE OF BIRTH: SEX:


_________________________________ ____________________ __________
_________________________________ ____________________ __________
_________________________________ ____________________ __________
_________________________________ ____________________ __________
4.A. Other children under her care
NAME DATE OF BIRTH SEX
________________________________ ____________________ ___________
________________________________ ____________________ ___________
________________________________ ____________________ ___________
5. NAME OF RESPONDENT: _________________________________________ AGE ___________
OCCUPATION/SOURCE OF INCOME: ________________________________________________________
ADDRESS: _____________________________________________________ CP# _____________________
CIVIL STATUS: ______ Single _________Married __________ Widower __________ Separated _________
6. Relationship of Complainant to Respondent:
______ Wife ________ Former Wife __________ Common Law/Live-in Relationship
______ Dating Relationship _____________ Sexual Relationship
7. Acts Complained of (Pls. Check)
________ Threats ____________ 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 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 bonafide 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 over Printed Name
Date Issued:

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