SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of ________________________________
(Required by R.A. 6713)
Note: Husband and wife who are both public officials and employees may file the required statements jointly or separately.
Joint Filing Separate Filing Not Applicable
DECLARANT: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:
ADDRESS: OFFICE ADDRESS:
SPOUSE: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:
OFFICE ADDRESS:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIING IN DECLARANT!S HOUSEHOLD
NAME DATE OF BIRTH AGE
ASSETS, LIABILITIES AND NETWORTH
(ncluding those of the spouse and unmarried children below eighteen (!"#
years of age li$ing in declarant%s household#
1" ASSETS
#" Re#$ P%o&e%t'e()
DESCRIPTION
(e.g. lot !ouse a"d lot
#o"domi"ium a"d
im$ro%eme"ts)
*IND
(e.g. reside"tial
#ommer#ial i"dustrial
agri#ultural a"d mi&ed use)
LOCATION ASSESSED
ALUE
CURRENT FAIR
MAR*ET ALUE
AC+UISITION AC+UISITION COST
(As fou"d i" t!e 'a& (e#laratio" of
Real )ro$erty)
YEAR MODE
S,-tot#$:
-" Pe%(o.#$ P%o&e%t'e()
DESCRIPTION YEAR AC+UIRED AC+UISITION COST/AMOUNT
S,-tot#$ :
TOTAL ASSETS (#/-):
0" LIABILITIES)
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
TOTAL LIABILITIES:
NET WORTH : Tot#$ A((et( $e(( Tot#$ L'#-'$'t'e( 1
) Additional sheet&s may be used' if necessary.
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(of (eclarant &(eclarant%s spouse& )nmarried *hildren +elow ,ighteen (!"# years of Age -i$ing in (eclarant%s Household#
&.e do not ha$e any business interest or financial connection.
NAME OF ENTITY/BUSINESS
ENTERPRISE
BUSINESS ADDRESS NATURE OF BUSINESS INTEREST
2/OR FINANCIAL CONNECTION
DATE OF AC+UISITION OF
INTEREST OR CONNECTION
RELATIES IN THE GOERNMENT SERICE
(.ithin the Fourth (egree of *onsanguinity or Affinity. nclude also +ilas' +alae and nso#
&.e do not /now of any relati$e&s in the go$ernment ser$ice#
NAME OF RELATIE RELATIONSHIP POSITION NAME OF AGENCY/OFFICE AND ADDRESS
I !ereby #ertify t!at t!ese are true a"d #orre#t stateme"ts of my assets liabilities "et *ort! busi"ess i"terests a"d
fi"a"#ial #o""e#tio"s i"#ludi"g t!ose of my s$ouse a"d u"married #!ildre" belo* eig!tee" (1+) years of age li%i"g i" my
!ouse!old a"d t!at to t!e best of my ,"o*ledge t!e abo%e-e"umerated are "ames of my relati%es i" t!e go%er"me"t *it!i" t!e
fourt! #i%il degree of #o"sa"gui"ity or affi"ity.
I !ereby aut!ori.e t!e /mbudsma" or !is0!er duly aut!ori.ed re$rese"tati%e to obtai" a"d se#ure from all a$$ro$riate
go%er"me"t age"#ies i"#ludi"g t!e 1ureau of I"ter"al Re%e"ue su#! do#ume"ts t!at may s!o* my assets liabilities "et
*ort! busi"ess i"terests a"d fi"a"#ial #o""e#tio"s to i"#lude t!ose of my s$ouse a"d u"married #!ildre" belo* 1+ years of age
li%i"g *it! me i" my !ouse!old #o%eri"g $re%ious years to i"#lude t!e year I first assumed offi#e i" go%er"me"t.
(ate2 ______________________________
(Signature of (eclarant# (Signature of *o0(eclarant&Spouse#
3o%er"me"t Issued I(2 3o%er"me"t Issued I(2
I( No.2 I( No.2
(ate Issued2 (ate Issued2
SUBSCRIBED AND SWORN to before me t!is day of affia"t e&!ibiti"g to me t!e abo%e-stated go%er"me"t issued
ide"tifi#atio" #ard.
_______________________________________
(1erson Administering 2ath#