Republic of the Philippines

REGIONAL TRIAL COURT

Eight Judicial Region, Branch ____
Bulwagan ng Katarungan
Magsaysay Boulevard, Tacloban City

____________________________,
Petitioner, TPO Case No. ___________
FOR: Violence Against
-versus- Women and Their Children
(R.A. No. 9262)
____________________________,
Respondent.
x-----------------------------------------------------------------------------------------x

PETITION
WITH PRAYER FOR THE ISSUANCE OF
A TEMPORARY PROTECTION ORDER

1. PETITIONER,

for and on behalf of the offended party

through the undersigned counsel,

2. The OFFENDENT PARTY is (name) _____________________,

and is the:

wife of the respondent

former wife of the respondent
common-law wife of the respondent
former common-law wife of the respondent
person being dated by the respondent
person formerly being dated by the respondent
person having a sexual relationship with the respondent
person formerly having a sexual relationship with the respondent
common child of mother and respondent
child by nature of mother
(specify other relationship): _______________________

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 3. The offended party currently resides at ____________________.

Disclosure of the address will pose danger to the life of the

offended party. The representative attests that the offended party residing in
the municipality or city over which the court has territory jurisdiction.
(Note: If the OFFENDED PARTY is staying at a DSWD or NGO shelter, do not give
address of the shelter but give the address as of the incident of violence against women
and children being complained of.)

4. The representative(s) is / are:

Parent(s) of the offended party

Guardian of the offended party

Ascendant, descendant or relative of the offended party with the

fourth civil degree of consanguinity or affinity

Officer or social worker of __________________________

Department of Social Welfare and Development (DSWD)

Local Government Unit (LGU)

Police Officer

in-charge of women and childrens desk

other police assignment

Punong Barangay of the barangay where the act of violence

against women and their women and their children occurred.

At least two concerned, responsible citizens of the place when

the act of violence against women and their children occurred.

Lawyer of the offended party

Counselor of the offended party

Therapist of the offended party

healthcare provider of the offended party

5. The representative(s) may be contacted at The Law Office of R.

Palomino, Unit 7, Second Floor, SDC II Building, Marasbaras, Brgy. 77,
Marasbaras, Tacloban City.

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 6. Respondent, who is about ___ years old, may be found at
______________________________________.

7. Parties may be served with summonses and other court processes

of the Honorable Court at their indicated addresses.

ANTECEDENT FACTS
WHICH LED TO THE FILING OF THE PETITION

8. Get details of the most recent event where the offended party
suffered an act of violence against women and their children which resulted
in PSYCHOLOGICAL VIOLENCE and/or ECONOMIC ABUSE:

WHEN: (Month) ______ (Day) ___, 2016 (Year)

TIME: ___________.
WHERE: _________________

Respondent has:

9. The MOST RECENT EVENT that caused the offended party to

fear immediate and imminent danger of violence against women and their
children is:

Date: (Month) (Day), 20 (Year)

Threatening verbal statements uttered: _____________________________

_____________________________________________________________
__________________________________________________________

Describe injuries sustained: ______________________________________

_____________________________________________________________
_____________________________________________________________
10. Describe weapons used or threatened to be
used:_________________________________________________________
_____________________________________________________________
(Use additional page if necessary: indicate at the top of page Item 8, Petition with
Prayer for TPO)

Others:

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 11. The offended partys designated family and household members:

No. Name Age Relationship

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12. Respondent has a history of violent behaviour such as:

13. The offended party a minor child has neither property

nor income with which to support

herself and the minor children,

himself herself and his her

mother guardian ad litem,

to pay attorneys fees and the expenses incurred in bringing the above
entitled action. Petitioner is, therefore, requesting the court to appear counsel
to assist him / her in prosecuting the case on behalf the offended
party.

14. Respondent is capable of providing support for

the offended party and the minor children,

the offended party minor children and

his her

mother guardian ad litem

paying attorneys fees and the expenses incurred in bringing the above
entitled action.

15. The aforesaid acts of violence have caused the offended party
great physical and mental pain, suffering and anguish and have seriously
impaired her / his physical and mental health and development.

16. Unless protected by this Honorable Court, there is

reasonable ground to believe that the respondent will inflict further violence
against the offended party, and that, for her / his protection, a
temporary protection order is, therefore, necessary to prevent the occurrence
or recurrence of such violence.

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 17. Unless protected by this Honorable Court, there is reasonable
ground to believe that the respondent will likewise inflict violence against
the family or household members of the offended party, and, for their
protection, they consent to a temporary protection order that the Honorable
Court may issue to prevent the occurrence or recurrence of such violence.

18. Unless restrained by this Honorable Court, there is great and

imminent danger that respondent will take the minor children out of
jurisdiction of the Honorable Court and hide them in another place where the
offended party will not able to find them.

PRAYERS

IN VIEW OF ALL THE FOREGOING, petitioner prays that:

(1) Upon the filing of this petition, the Honorable Court issue ex
parte in favor of the offended party a Temporary Protection Order:

Enjoining the respondent from the threatening to commit or

committing further acts of violence against offended party and
designated family and household member(s):

Name Age Relationship

(Use additional page if necessary, indicate at the top of page Prayer-Protected

Designated Family and Household Members, Petition with Prayer for TPO)

Ordering the respondent to stay away at a distance of more or less

250 meters from:

the offended party

designated family and household members
the residence of the offended party
the school of the offended party
the place of employment of the offended party
the ____________ (specify) frequented by the offended party
the _______________ (specify) frequented by the designated
family and household member;

Granting the exclusive possession of the residence to the offended

party;

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 Ordering the respondent to pay the offended partys rent a
residence other than the one previously shared as respondent has a
duty to support her / him;

Granting to the offended party custody and charge of the minor

children, until further orders from this Court;

Ordering the respondent to absolutely desist and refrain from

imposing any restrain on the personal liberty of the offended party
and from her custody or charge any of said minor children.

Ordering the respondent from further communicating in any

any form, e.g. landline telephone, mobile telephone, fax machine,
email and other means, with the offended party and her minor
children are studying; in the place of her employment; and in the
malls, churches, school of their son she frequents; and

Ordering a law enforcement officer or barangay official to

accompany either party to the residence to supervise the removal
of personal belongings in order to ensure the personal safety of the
offended party.

Others:

(2) After hearing, judgment be rendered in the offended partys favor

by making Temporary Protection Order prayed for.

Other reliefs just and equitable in the premises are prayed for.