Revised as of Janus.ry 2015
Per CSC Resolution No. 1500088
Promulgated on January 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of
(Required by RA 6713)
Note: Husband and wife who are both public officials and employees may file the required statements jointly or separately.
0 Joint Filing
0 Separate Filing
DECLARANT:
U Not Applicable
(Family Name)
(First Name)
(Ml.)
POSITION:
AGENCY/OFFICE:
OFFICE ADDRESS:
(Family Name)
(First Name)
(Mt)
POSITION:
AGENCY/OFFICE:
OFFICE ADDRESS:
ADDRESS:
SPOUSE:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT'S HOUSEHOLD
NAME
DATE OF BIRTH
AGE
ASSETS, LIABILITIES AND NETWORTH
(Including those of the spouse and unmarried children below eighteen (18)
years of age living in declarant's household)
1. ASSETS
Real Properties*
DESCRIPTION
KUM
(e.g. lot, house and
lot, condominium
and improvements)
(e.g. residential,
commercial, industrial,
agricultural and mixed
use)
EJCASIF
LOCATION
ASSESSED
CURRENT FAIR
VALUE
MARKET VALUE
(As found in the Tax Declaration of
Real Property)
ACQUISITION
ACQUISITION
COST
YEAR
MODE
Subtotal:
Personal Properties*
YEAR ACQUIRED
DESCRIPTION
ACQUISITION
COST/AMOUNT
Subtotal:
TOTAL ASSETS (a+b):
* Additional sheet/ s may be used, if necessary.
Page 1 of
2. LIABILITIES*
NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
TOTAL LIABILITIES:
NET WORTH : Total Assets less Total Liabilities =
* Additional sheet/ s may be used, ((necessary.
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(of Declarant /Declarant's spouse/ Unmarried Children Below Eighteen (18) years of Age Luring in Declarant's Household)
ci I/ We do not have any business interest or financial connection.
NAME OF ENTITY/BUSINESS
ENTERPRISE
BUSINESS ADDRESS
NATURE OF BUSINESS
INTEREST 136/OR FINANCIAL
CONNECTION
DATE OF ACQUISITION OF
INTEREST OR CONNECTION
RELATIVES IN THE GOVERNMENT SERVICE
(Within the Fourth Degree of Consanguinity or Affinity. Include also Biles, Balae and Inso)
l/ We do not know of any relative/sin the government service)
NAME OF RELATIVE
RELATIONSHIP
POSITION
NAME OF AGENCY/OFFICE AND ADDRESS
I hereby certify that these are true and correct statements of my assets, liabilities, net worth,
business interests and financial connections, including those of my spouse and unmarried children below
eighteen (18) years of age living in my household, and that to the best of my knowledge, the aboveenumerated are names of my relatives in the government within the fourth civil degree of consanguinity or
affinity.
I hereby authorize the Ombudsman or his/her duly authorized representative to obtain and
secure from all appropriate government agencies, including the Bureau of Internal Revenue such
documents that may show my assets, liabilities, net worth, business interests and financial connections,
to include those of my spouse and unmarried children below 18 years of age living with me in my
household covering previous years to include the year I first assumed office in government.
Date:
(Signature of Co-Declarant/Spouse)
(Signature of Declarant)
Government Issued ID:
ID No.:
Date Issued:
Government Issued ID:
ID No.:
Date Issued:
SUBSCRIBED AND SWORN to before me this
government issued identification card.
day of
affiant exhibiting to me the above-stated
(Person Administering Oath)
Page 2 of
Revised as of January 2015
Per CSC Resolution No. 1500088
Promulgated on January 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of
(Additional sheet/ s for the exclusive properties of the declarant's spouse and unmarried children
below eighteen (18) years of age living in declarant's household)
NAME:
POSITION:
(Family Name)
(First Name)
(ML)
AGENCY/OFFICE:
ASSETS, LIABILITIES AND NET WORTH
1. ASSETS
Real Properties
DESCRIPTION
(e.g. bt, house and
lot, condominium
and improvements)
KIND
EXACT
(e.g. residential,
commercial, industrial,
agricultural and mixed
usel
LOCATION
:
VALUE
T FAIR
ACQUISITION
MARKET VALUE
(As found in the Tax Declaration of
Real Propenyl
ACQUISITION
COST
YEAR
MODE
Personal Properties
DESCRIPTION
YEAR ACQUIRED
ACQUISITION
COST/AMOUNT
2. LIABILITIES
NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
NAME OF ENTITY/BUSINESS
ENTERPRISE
BUSINESS ADDRESS
_I
_
NATURE OF BUSINESS
INTEREST 8i/OR FINANCIAL
CONNECTION
Page of
DATE OF ACQUISITION OF
INTEREST OR CONNECTION
Revised as of January 2015
Per CSC Resolution No. 1500088
Promulgated on January 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of
(Additional sheet/ s for the declarant)
NAME:
(Family Name)
(First Name)
POSITION:
AGENCY/OFFICE:
(M. I.)
ASSETS, LIABILITIES AND NET WORTH
1. ASSETS
Real Properties
DESCRIPTION
KIND
EXACT
ASSESSED
CURRENT FAIR
(e.g. lot, house and
lot, condominium
and improvements)
(e.g. residential,
commercial, Industrial,
agricultural and mixed
use)
LOCATION
VALUE
MARKET VALUE
(As found in the Tax Declaration of
Real Property)
ACQUISITION
ACQUISITION
COST
YEAR
MODE
Subtotal:
Personal Properties
DESCRIPTION
YEAR ACQUa
ACQUISITION COST/AMOUNT
Subtotal:
TOTAL ASSErs (a+b):
2. LIABILITIES
NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
TOTAL LIABILITIES:
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
NAME OF ENTITY/BUSINESS
ENTERPRISE
BUSINESS ADDRESS
NATURE OF BUSINESS
INTEREST di/OR FINANCIAL
CONNECTION
Page _of
DATE OF ACQUISITION OF
INTEREST OR CONNECTION