SWORN STATEMENT OF ASSETS, LIABILITIES, AND NET WORTH, DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS, AND IDENTIFICATION

OF RELATIVES IN THE GOVERNMENT SERVICE As of December 31, !Re"#$re% b& Re'#b($c Ac) No* +,13N.me/ Surname A%%ress/ N.me of S'o#se/ Surname First Name M.I . First Name M.I . 0os$)$o12I1come/ Off$ce/ Off$ce A%%ress/ 0os$)$o12Occ#'.)$o1/ Off$ce/

U1m.rr$e% C3$(%re1 be(o4 15 &e.rs of .6e/ N.me D.)e of B$r)3

A* ASSETS, LIABILITIES AND NET WORTH 1* ASSETS .* Re.( 0ro'er)$es Ac"#$s$)$o1 Cos) 7$1% Loc.)$o1 8e.r Ac"#$re% Mo%e of Ac"#$s$)$o1 Assesse% V.(#e C#rre1) F.$r M.r9e) V.(#e L.1%, B#$(%$16, e)c* Im'ro:eme1)s

TOTAL !1.- 0 b* 0erso1.( .1% O)3er 0ro'er)$es 7$1% 8e.r Ac"#$re% Ac"#$s$)$o1 Cos)

TOTAL ASSETS !1. ; 1b<* LIABILITIES !Lo.1s, Mor)6.6es, e)c*N.)#re

TOTAL !1b- 0 TOTAL 0 Amo#1)

TOTAL !<- 0 NET WORTH =To).( Asse)s !1. ; 1b- Less To).( L$.b$($)$es !<- > TOTAL 0

(NOTE/ Please use additional forms / sheets if necessary. Also, please reproduce this form back to back.)

B* BUSINESS INTERESTS AND FINANCIAL CONNECTIONS Do you have any business interests and other financial connections including those of your spouse and unmarried children below ! years of age living with you in your household" #es $o %f yes, give particulars& N.me of F$rm2 Com'.1& N.)#re of B#s$1ess I1)eres) .1%2or F$1.1c$.( Co11ec)$o1s D.)e of Ac"#$s$)$o1 or Co11ec)$o1

N.me

A%%ress

C* IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE 'o the best of your knowledge, are you related within the fourth degree of consanguinity or of affinity to anyone working in the government" #es $o %f yes, give particulars& N.me 0os$)$o1 Re(.)$o1s3$' N.me2A%%ress of Off$ce

% hereby certify to the best of my knowledge and information that these are true statements of my assets, liabilities, net worth, business interests and financial connections, including those of my spouse and unmarried children below ! years of age and names of my relatives in the government as of December ( , )))))))), as re*uired by and in accordance with +epublic Act ,- (. % hereby authori.ed the /mbudsman or his duly authori.ed representative to obtain and secure from all appropriate government agencies, including the 0ureau of %nternal +evenue, 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 ! years of age living with me in my household covering past years to include the year % first assumed office in government. Date&

1ignature of 1pouse '%$ 3om. 'a4 3ert. $o. %ssued at %ssued on

1ignature of 2mployee '%$ 3om. 'a4 3ert. $o. %ssued at %ssued on

SUBSCRIBED AND SWORN TO before me this ))))))))day of )))))))))))))))), 56 )))), affiant e4hibiting his/her 3ommunity 'a4 3ertificate as indicated above.

0erso1 A%m$1$s)er$16 O.)3