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Republic of the Philippines

Province of Cebu
Barangay _______________, _____________, Cebu
Office of the Barangay Captain
Lupong Tagapamayapa

_________________________________
____________
_________________________________
____________________
Petitioner,
vs.
_________________________________
_________________________________
Respondent,
/-----------------------------------------------------X

Bry. Case No.


For:

PETITION FOR THE ISSUANCE OF A


BARANGAY PROTECTION ORDER (BPO)
COMES NOW, the petitioner, by:
( ) a. Herself
( ) b. Parent(s) or Guardian
( ) c. Ascendant, Descendant or relative within the Fourth Civil
Degree of
(
(
(
(

)
)
)
)

consanguinity or affinity
d. Officer or Social Worker of DSWD or LGU
e. Police Officer
f. Punong Barangay or Barangay Kagawad
g. Lawyer, Counselor, Therapist or Healthcare provider of

petitioner
( ) h. 2 concerned responsible citizens of the city, municipality or
barangay
Unto this Honorable office, most respectfully avers:
1.

That the Petitioner is of Legal Age, Filipino Citizen and a resident of


__________________________________________________________________,
Cebu;
2. That the Petitioner is the Wife/Former Wife/Live-in Partner/Child of the
respondent;

3. That the Respondent is the Husband/Former Husband/Live-in


Partner/Father/Step-Father of the Petitioner and they lived together
in the above-mentioned address;
4.
That on _______________________, 20____, Respondent has committed
acts of violence as defined by Republic Act 9262 against the person of the
Petitioner which is more specifically described as follows:
a. Physical harm including any form of bodily injury that may be one or a
combination of the following analogous act:
( ) a.a Hitting, punching, slapping, grabbing, biting,, kicking,. Breaking
bones, bruising, burning, pulling of hair, throwing of victim against the wall
or furniture, banging victim on the floor or surface or against any object;
( ) a.b Throwing objects at the victim, hitting the victim with an object or
assaulting the victim using a deadly weapon;
( ) a.c Compelling, coercing or causing the intake of alcohol, drugs or
other dangerous substance by intimidation, force threat of use of force;
( ) a.d Others:
_____________________________________________________________________________
_________________________________________________________________________
b. Threatening to cause the woman or child physical harm such as:
_____________________________________________________________________________
_____________________________________________________________________________
______________________________________________________________
5.

That the respondent is:

( ) Unemployed
( ) Employed, working at _____________________________________________
Located at ______________________________________________________
As a ___________________________________________________________
6.
1.
2.
3.

That the Respondent and Petitioner has _______( ) Children, Namely:


____________________________________ age: ______________
____________________________________ age: ______________
____________________________________ age: ______________

7.
That the petitioner could no longer bear the situation she is suffering
from the hands of the Respondent;
8.
That the Petitioner hereby attaches the following documents that will
form part of the Petition as evidence:

a.
b.
c.
d.

__________________________________
__________________________________
__________________________________
__________________________________

marked
marked
marked
marked

as
as
as
as

Annex
Annex
Annex
Annex

A
B
C
D

9.
That the Petitioner would like to apply for a Barangay Protection
Order (BPO) granted to her under Republic Act 9262 otherwise known as
Anti-Domestic Violence Against Women and Their Children Act of 2004.
PRAYER
WHEREFORE, premises considered it is respectfully requested from this
Honorable Office to issue a BPO against Respondent as prescribed under
Republic Act 9262.
( ) a. Prohibit the Respondent, personally or through another person from
committing any act of violence against the petitioner as defined by RA 9262.
( ) b. Prohibit the Respondent from directly or indirectly telephoning,
contacting or communicating the Petitioner.
( ) c. Prohibit the Respondent from harassing and annoying the Petitioner.
( ) d. Prohibit the Respondent from taking or attempting to take personally
or through another, ____________________________, from Petitioner.
______________________________, 2011, Province of Cebu.

________________________________
Petitioner/Representative
CTC No. : ___________________________
Issued on : __________________________
Issued at : __________________________
SUBSCRIBED AND SWORN to before me this ___________ day of
___________________. 20____, in _______________________________, Philippines.