CBF 12

Motion for Issuance of TPO

Original Court, 1st Copy Prosecutor, 2nd Copy Accused, Other copies as needed
Enter information in block letters in all parts of the Form except when reserved for Court use, which shall be
completed by the Clerk.

For Court Use Only

(Judicial Region)

METC/MTCC/MTC/MCTC Case No.

RTC
(Municipality/City/Province)

BRANCH

People of the Philippines , v.

,
Accused.

ATTORNEY OR PARTY WITHOUT ATTORNEY

Name
Firm Name
Address
Email Address
Tel./Cel./Fax Nos.
PTR No. Date/Place of Issuance
Roll No. Date/Place of Issuance
IBP No. Lifetime Date/Chapter
MCLE Compliance Exemption No.

Other Compliances

Attorney for
Prosecution: Public Prosecutor Private Prosecutor
Defense: Public Attorney Private Counsel
Other

APPLICATION FOR ISSUANCE OF A

TEMPORARY PROTECTION ORDER

Movant, , states:
1. Movant is
the offended party.
the parent or guardian of the offended party
ascendant, descendant or collateral relative within the fourth civil
degree of consanguinity or affinity
an officer or social worker of the DSWD or social workers of local
government units (LGUs);
a police officer, preferably in charge of women and children's desks;
Punong Barangay or Barangay Kagawad;
the lawyer, counselor, therapist or healthcare provider of the
petitioner;
a concerned responsible citizens of the city or municipality where the
violence against women and their children occurred and who has
personal knowledge of the offense committed.

2. The details of the parties are as follows:

Name Age Residence
Offended party
Accused

3. The offended party is the of the accused.

4. The offended party fears immediate and imminent danger of violence

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Motion for Issuance of TPO

against her and/or her child/ren because of the following events:

(specify details of the abuse, i.e.: physical violence, sexual
violence, psychological violence, economic abuse)

5. The aforesaid acts of violence have caused the movant great physical and
mental pain, suffering and anguish and have seriously impaired her physical and
mental health and development.

6. Until protected by this Honorable Court, there is reasonable ground to

believe that the accused will inflict further violence against the movant and/or her
child/ren, and that, for her/their protection, a temporary protection order is
necessary to prevent the occurrence or recurrence of such violence.

7. There is also reasonable ground to believe that the accused will inflict
violence against the family or household members of the movant, 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.

8. the applicant requests for counsel because: (state reason)

9. the applicant requests for waiver of application fees

10. the applicant is not the offended party. Hence, the affidavit required
under Section 10 A.M. No. 4-10-11-SC is attached.

11. Movant prays for the issuance ex-parte of a Temporary Protection Order
enjoining the accused from threatening to commit or committing further acts of
violence against the offended party and the following family and household
member(s):

Name Age Relationship

Ordering the accused to stay away at a distance of meters from:

The applicant
Designated family and household members
The residence of the applicant
The school of the applicant
The place of employment of the applicant
The (specify) frequented by the applicant
The (specify) frequented by designated family and
household members

Ordering the accused from further communicating in any form with the
movant and/or her minor child/ren in the residence, in the school where the
movants minor child/ren are studying, in the place of employment of the
movant, and in the (specify) frequented by the movant.

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Motion for Issuance of TPO

Movant further prays that, after hearing, the Temporary Protection Order be
made permanent.

Date Party/Partys Counsel

VERIFICATION

Complainant , of legal age, single/married, and a resident of ,

after having been duly sworn in accordance with law, depose and state that:

1. I am the movant in this case.

2. I caused the preparation of the foregoing Motion.
3. I have read the contents thereof and the facts stated therein are true and
correct of my personal knowledge or based on authentic records.

Name Date

SUBSCRIBED AND SWORN to before me this day of

20 at movant exhibiting to me (government issued ID) No.
issued on at City.

Notary Public

Doc No. ;
Page No. ;
Book No. ;
Series of 20

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Motion for Issuance of TPO

PROOF OF SERVICE

A copy of this Motion was served upon parties and/or their counsel(s) on via
Personal Service
Facsimile or other Electronic Means

and received by the parties and/or their counsel(s) on .

Proof of such service is attached to this Motion as Annex .

ORDER

After a review of the Motion, the same is

GRANTED. Let a Temporary Protection Order issue against the accused

, enjoining the accused from threatening to commit or committing
further acts of violence against the offended party and the following
family and household member(s):

Name Age Relationship

Ordering the accused to stay away at a distance of 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
(specify place) frequented by the offended party
(specify place) frequented by designated family and
household members

Ordering the accused from further communicating in any form with the
movant and/or her minor child/ren in the residence, in the school where the
movants minor child/ren are studying, in the place of employment of the
movant, and in (specify place) frequented by the movant.

This temporary protection order is effective only for thirty (30) days
from service on the accused.

DENIED, because (state reason). The accused is directed to file

a Comment on the application for a permanent protection order within five (5)
days from receipt.

Judge Date

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Motion for Issuance of TPO

COPY FURNISHED

Persons Name Method Place Served Date

Served
Personal Service
Trial Prosecutor Courier Service
Facsimile, Email,
SMS
Personal Service
Counsel for Accused Courier Service
Facsimile, Email,
SMS
Personal Service
Private Complainant Courier Service
Facsimile, Email,
SMS
Personal Service
Accused Courier Service
Facsimile, Email,
SMS
Personal Service
Courier Service
Facsimile, Email,
SMS
Personal Service
Courier Service
Facsimile, Email,
SMS

SPECIAL INSTRUCTIONS

Copies to be filed with the Court

An original of this Form must be filed with the Court together with such additional copies
equivalent to the number of parties in the case, to be used by the Court in sending out its court
order contained in the same Form.

Form of petition
A petition for protection order shall be in writing, signed and verified by the petitioner. It shall
be accompanied by a certificate of non-forum shopping which the petitioner must sign
personally. (Section 7, A.M. No. 4-10-11-SC)

Who may file petition

A petition for protection order may be filed by any of the following:
(a) The offended party;
(b) Parents or guardians of the offended party;
(c) Ascendants, descendants or collateral relatives of the offended party within the fourth
civil degree of consanguinity or affinity;
(d) Officers or social workers of the Department of Social Welfare and Development
(DSWD) or social workers of local government units (LGUs);
(e) Police officers, preferably those in charge of women and children's desks;
(f) Punong Barangay or Barangay Kagawad;
(g) Lawyer, counselor, therapist or healthcare provider of the petitioner; or
(h) At least two concerned, responsible citizens of the place where the violence against
women and their children occurred and who have personal knowledge of the offense
committed.

The filing of a petition for protection order by the offended party suspends the right of all other
authorized parties to file similar petitions. A petition filed by the offended party after the filing of
a similar petition by an authorized party shall not be dismissed but shall be consolidated with the
petition filed earlier. (Section 8, A.M. No. 4-10-11-SC)

Where to file the petition

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The verified petition for protection order may be filed with the Family Court of the place where
the offended party resides. If there is no existing Family Court, it may be filed with the regional
trial court, metropolitan trial court, municipal trial court in cities, municipal trial court or
municipal circuit trial court with territorial jurisdiction over the place of residence of the
offended party. (Section 9, A.M. No. 4-10-11-SC)

Contents of the petition

The petition filed by the offended party shall contain the following:
(a) The name, age and residence of the offended party;'
(b) The name, age and residence of the respondent;
(c) A description of the relationship between the offended party and the respondent;
(d) A complete description of the alleged act constituting violence including the date, time
and place of occurrence;
(e) A request for counsel and the reasons for such;
(f) A request for waiver of application fees;
(g) The relief from violence prayed for, including protection orders to cover any designated
family or household member who consents to such relief.

If the petitioner is not the offended party, the petition shall be accompanied by an affidavit of the
petitioner attesting to the following:
(a) facts showing the authority of the petitioner to file the petition;
(b) circumstances of the abuse suffered by the offended party; and
(c) circumstances of consent given by or refusal to consent of the offended party to file the
petition.

When disclosure of the address will pose danger to the life of the offended party, it shall be so
stated in the petition. In such a case, the petitioner shall attest that the offended party is; residing
in the municipality or city over which the court has territorial jurisdiction, and shall provide a
mailing address for purposes of service processing. (Section 10, A.M. No. 4-10-11-SC)

Reliefs available to the offended party

The protection order shall include any, some or all of the following reliefs:
(a) Prohibiting the respondent from threatening to commit or committing, personally or
through another, acts of violence against the offended party;
(b) Prohibiting the respondent from harassing, annoying, telephoning, contacting or
otherwise communicating in any form with the offended party, either directly or
indirectly;
(c) Removing and excluding the respondent from the residence of the offended party,
regardless of ownership of the residence, either temporally for the purpose of protecting
the offended party, or permanently where no property rights are violated. If the
respondent must remove personal effects from the residence, the court shall direct a law
enforcement agent to accompany the respondent to the residence, remain there until the
respondent has gathered his things and escort him from the residence;
(d) Requiring the respondent to stay away from the offended party and any designated family
or household member at a distance specified by the court;
(e) Requiring the respondent to stay away from the residence, school, place of employment
or any specified place frequented regularly by the offended party and any designated
family or household member;
(f) Directing lawful possession and use by the offended party of an automobile and other
essential personal effects, regardless of ownership, and directing the appropriate law
enforcement officer to accompany the offended party to the residence of the parties to
ensure that the offended party is safely restored to the possession of the automobile and
other essential personal effects;
(g) Ordering temporary or permanent custody of the child/children with the offended party,
taking into consideration the best interests of the child. An offended party who is
suffering from Battered Woman Syndrome shall not be disqualified from having custody
of her children. In no case shall custody of minor children be given to the batterer of a
woman who is suffering from Battered Woman Syndrome;
(h) Directing the respondent to provide support 'o the woman and/or her child, if entitled to
legal import. Notwithstanding other laws to the contrary, the court shall order an
appropriate percentage of the income or salary of the respondent to be withheld regularly
by his employer and to automatically remit it directly to the offended party. Failure to

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withhold, remit or any delay in the remittance of support to the offended party without
justifiable cause shall render the respondent or his employer liable for indirect contempt
of court;
(i) Prohibiting the respondent from carrying or possessing any firearm or deadly weapon and
ordering him to surrender the same to the court for appropriate disposition, including
revocation of license and disqualification to apply for any license to carry or possess a
firearm. If the respondent is .a law enforcement agent, the court shall order him to
surrender his firearm and shall direct the appropriate authority to investigate him and take
appropriate action thereon;
(j) Directing the DSWD or any appropriate agency to prepare a program of intervention for
the offended party that provides advocacy, temporary shelter, crisis intervention,
treatment, therapy, counseling, education, training and other social services that the
offended party may need;
(k) Requiring the respondent to receive professional counseling from agencies or persons
who have demonstrated expertise and experience in anger control, management of
alcohol, substance abuse and other forms of intervention to stop violence. The program of
intervention for offenders must be approved by the court. The agency or person is
required to provide the court with regular reports of the progress and result of
professional counseling, for which the respondent may be ordered to pay; and
(I) Awarding the offended party actual damages caused by the violence inflicted,
including, but not limited to, property damage, medical expanses, childcare
expenses and loss of income; and compensatory, moral, and exemplary
damages, subject to Sections 26a and 35 of this Rule.

The court may grant such other forms of relief to protect the offended party and any designated
family or household member who consents to such relief. (Section 11, A.M. No. 4-10-11-SC)

Application of foregoing provisions

The foregoing provisions shall also apply to applications for protection orders filed as incidents
in criminal or civil actions. (Section 32, A.M. No. 4-10-11-SC)

Who may file Petition for Protection Orders

A petition for protection order may be filed by any of the following:
(a) the offended party;
(b) parents or guardians of the offended party;
(c) ascendants, descendants or collateral relatives within the fourth civil degree of
consanguinity or affinity;
(d) officers or social workers of the DSWD or social workers of local government units
(LGUs);
(e) police officers, preferably those in charge of women and children's desks;
(f) Punong Barangay or Barangay Kagawad;
(g) lawyer, counselor, therapist or healthcare provider of the petitioner;
(h) At least two (2) concerned responsible citizens of the city or municipality where the
violence against women and their children occurred and who has personal knowledge of
the offense committed. (Section 9, RA 9262)

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