Republic of the Philippines
City of Caloocan
BARANGAY 52, Zone 5, District 2
6TH AVENUE GRACE PARK CALOOCAN CITY
0931-9962878 / 0915-2161364
OFFICE of the PUNONG BARANGAY
BARANGAY CERTIFICATE
This is to certify that LENARD MACABENTA GURION, Filipino citizen, with resident
address at #69 FD YABUT ST. 7TH AVENUE, GRACE PARK CALOOCAN CITY.
This further certifies that the bearer is a bonafide resident of this barangay for many years, and
has no derogatory records whatsoever.
This certification is being issued upon the request of LENARD MACABENTA GURION. as a
proof of his/her residency, as per requirement for BANK TRANSACTION PURPOSES.
Issued this 27TH day of September, 2024 at Pamahalaang Barangay of Barangay 52, Zone 5,
District 2, City of Caloocan.
Valid for 3 months from the date of issuance.
Certified by:
HON. JOHNNY C. SY
PUNONG BARANGAY
NOT VALID WITHOUT OFFICIAL SEAL
APPLICATION FOR BARANGAY PROTECTION ORDER
Page 1 of 2
MM DD YYYY
Name of Applicant: Date of Birth: / /
Address:
Contact Details: Occupation:
Relationship to Victim/s:
Name of Victim/s: Date of Birth: / /
Address:
Contact Details: Occupation/Source of Income:
Civil Status: Single Married Widowed Separated
Legally Separated
Name/s of children: Date of Birth Sex
Other children under her care
Name of Respondent: Date of Birth: / /
Page 2 of 2
Address:
Contact Details: Occupation/Source of Income:
Civil Status: Single Married Widowed Separated
Legally Separated
Relationship of victim to respondent:
Wife Former Wife Live-in Partner
Dating Sexual Relationship
Acts complained of: Threats Physical Injuries Sexual
Psycho Psychosocial Economic
Rape Anti-Trafficking
Description:
Date/s of Commission: Place/s of Commission:
If applicant is not the victim, state the circumstances of the consent:
Signature over Printed Name of the Applicant Date
VERIFICATION OF THE PUNONG BARANGAY
I certify that the applicant for Barangay Protection Order (BPO) who personally
appeared before me is a bonafide resident of this barangay and is the same person who
supplied the above information and attested to the correctness of said information.
Page 3 of 2
Name
Punong Barangay
Date Issued:
Page 4 of 2
