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1. Republic of the Philippines
City/Municipality of ___________________
Province of ________________
BARANGAY ________________
OFFICE OF THE PUNONG BARANGAY
Petitioner: Respondent:
Address: Address:
Full Name of
Perpetrator/Respondent:
Date of
Birth
Sex Height Weight
Distinguishing
Marks
Full Name of Protected Person/s:
Date of
Birth
Sex Height Weight
Distinguishing
Marks
The above-named PERPETRATOR/RESPONDENT is hereby ordered to desist from:
1. Threatening to commit or commit, personally or through another, any of the following
acts mentioned in Section 5 (a) and (b) of Republic Act No. 9262;
(a) Causing physical harm to the woman (Petitioner) or her child;
(b) Threatening to cause the woman (Petitioner) or her child physical harm;
2. Harassing, annoying, telephoning, contacting or otherwise communicating with the
woman (Petitioner), directly or indirectly.
BARANGAY PROTECTION ORDER (BPO)
Pursuant to Republic Act No. 9262
(Anti-Violence Against Women and Their Children Act of 2004)

2. THIS BARANGAY PROTECTION ORDER IS VALID
From: Until:
VIOLATION OF THIS ORDER IS PUNISHABLE BY LAW
ISSUED this ______ day of _________________, 20___ _______o’clock a.m./p.m. at
Barangay ___________, ___________, __________, Philippines.
___________________________
Punong Barangay/
Barangay Kagawad
OFFICER’S RETURN
I served this Barangay Protection Order (BPO) upon Respondent __________
______________________ at his last known address at No. _____ _________________ St,
Barangay___________, ___________, __________on ______________ ____, 20____, at
_______ a.m./p.m. by:
(Encircle mode by which the Respondent was served.)
1. Handing to the Respondent said Barangay Protection Order (BPO) in person, or
2. Handing to the Respondent said Barangay Protection Order (BPO) and he refused
to receive it, or
3. Leaving said Barangay Protection Order (BPO) at the Respondent’s dwelling with
_______________________ (name), a person of suitable age and discretion
residing therein, or
4. Leaving said Barangay Protection Order (BPO) at his office/place of business with
_______________________ (name), a competent person in charge thereof.
___________________________
Punong Barangay/Kagawad
Barangay Official
Received by Respondent/’s representative:
___________________ ________________ _________
Signature Date Time