Republic of the Philippines

REGIONAL TRIAL COURT

Branch 7
Tacloban City, Leyte

______________________________, TPO Case No. ________

Petitioner (Representative),

-versus- Violence Against Women and

Their Children (RA 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 undersigned counsel,
unto this Honorable Court, respectfully states and alleges:

THE PARTIES AND RELATIONSHIP

2. The OFFENDED PARTY is _________________________________,

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 sexual relationship with the respondent
person formerly having 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 is residing
in the municipality or city over which the court has territorial 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 date 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 if the offended party within 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 children’s desks
Other police assignment
Punong barangay of the barangay where the act of violence against
women and their children occurred
At least two concerned, responsible citizens of the place where the act
of violence against women and their children occurred
Lawyer of the offended party
Counsellor of the offended party
Therapist of the offended party
Healthcare provider of the offended party

5. The representative(s) may be contacted at

_____________________________________________________________

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.

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 ANTECEDENT FACTS
WHICH LED TO THE FILINNG OF THE PETITION

8. 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:

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

9. Respondent has a history of violent behavior such as:

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

10. 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 attorney’s fees and their expenses incurred in bringing the above-
entitled action. Petitioner is, therefore, requesting the court to appoint
counsel to assist him / her in prosecuting the case on behalf of the
offended party.

11. Respondent is capable of providing support for

the offended party and the minor children
the offended party – minor children,
his her
mother guardian ad litem

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paying attorney’s fees and the expenses incurred in bringing the above-
entitled action.

GROUNDS FOR THE ISSUANCE OF

A TEMPORARY PROTECTION ORDER

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

13. 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.

14. 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.

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

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

PRAYER

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 threatening to commit or

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

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(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 meters

from:

the offended party

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

Granting the exclusive possession of the residence to the

offended party;

Ordering the respondent to pay the offended party’s rent at 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 restraint on the personal liberty of the offended
party and from taking from her custody or charge any of said
minor children;

Ordering the respondent from further communicating in any

form, e.g., landline telephone, mobile telephone, fax machine,
e-mail and other means, with the offended party and her minor
children in the residence respondent was ordered to vacate
from; in the school where offended party’s minor children are
studying; in the place of her employment; and in the (specify)
_____________________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.

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 (2) After hearing, judgment be rendered in the offended party’s
favor by making permanent the Temporary Protection Order prayed for.

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

_________________________
(Petitioner)

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 VERIFICATION
AND
CERTIFICATION OF NON-FORUM SHOPPING

I, ___________________________________________, Filipino, of
legal age, and residing at ____________________________________, after
having been duly sworn in accordance with law, depose and state that:

1. I am the representative of the offended party in the above-entitled

case;

2. I filled up the foregoing petition with the assistance of the Clerk of

Court. I have read and understood the allegations therein and the
same are true and correct of my own knowledge and based on
authentic records;

3. I certify and attest that:

a) I have not commenced any action or filed any claim involving

the same issues in any court, tribunal or quasi-judicial agency
and, to the best of my knowledge, no such other action or claim
is pending therein;

b) If there is such other pending action or claim, I will furnish this

Honorable Court with a complete statement of the present status
thereof; and

c) If I should thereafter learn that the same or similar action or

claim has been filed or is pending, I shall report that fact within five
(5) days therefrom to this Honorable Court wherein my aforesaid
petition has been filed.

Affiant further sayeth naught.

________________________
(date)

_________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, , this _______ day

of _______________, 20___, at Tacloban City, Leyte.

_________________________
Administering Officer

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REPUBLIC OF THE PHILIPPINES)
______________________________) S.S.
______________________________)

AFFIDAVIT OF INDIGENCY

I, ____________________________________, Filipino, of legal age,

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

1. I am the representative of the offended party in the above-entitled petition;

2. I filled up the foregoing petition with the assistance of the Clerk of Court;

3. Pursuant to Section 21, Rule 3, 1997 Rules of Civil Procedure, I am

attesting to the fact thar
the offended party
the offended party – minor child
is not in a financial position to pay the entire docket and other lawful
fees, as
the offended party does not have
the offended party – minor child does not have
money of property sufficient and available for food, shelter and basic
necessities for
herself and her children
himself herself and
his her
mother guardian ad litem
Affiant further sayeth naught.

_________________________
Affiant

SUBSCRIBED AND SWORN TO BEFORE ME, , this _______ day of

_______________, 20___, at Tacloban City, Leyte.

_________________________
Administering Office