FORM 3 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 December 31, 2016
(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 EBUENGA, GENEVIEVE M. POSITION: EGT - II

:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: P. GUEVARA E/S, DEPED MANILA
ADDRESS: 2015-A OROQUIETA ST. STA. CRUZ, MANILA OFFICE ADDRESS: San Fernando St., San Nicolas,
Manila

SPOUSE: EBUENGA MABEL R. POSITION: EGT - I

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: P. GUEVARA E/S, DEPED MANILA
OFFICE ADDRESS: San Fernando St., San Nicolas,

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANTS HOUSEHOLD

NAME DATE OF BIRTH AGE

KATE DHENIELLE R. EBUENGA MARCH 16, 2012 5

ASSETS, LIABILITIES AND NETWORTH

(Including those of the spouse and unmarried children below eighteen (18)
years of age living in declarants household)

1. ASSETS
a. Real Properties*

DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION

(e.g. lot, house and (e.g. residential, LOCATION VALUE MARKET VALUE COST
lot, condominium commercial, industrial,
(As found in the Tax Declaration of
and improvements) agricultural and mixed YEAR MODE
Real Property)
use)

N/A N/A N/A N/A N/A N/A N/A N/A

Subtotal:
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

APPLIANCES/FURNITURES 2016 20,000.00

CLOTHINGS 2016 10,000.00
GADGETS 2016 10,000.00
BOOKS 2016 10,000.00
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 Subtotal : 50,000.00

TOTAL ASSETS (a+b): 50,000.00

* Additional sheet/s may be used, if necessary.

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2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

PERSONAL LOAN SISTER 25,000.00

TOTAL LIABILITIES: 25,000.00

NET WORTH : Total Assets less Total Liabilities = 25,000.00
* Additional sheet/s may be used, if necessary.

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

(of Declarant /Declarants spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarants Household)

I/We do not have any business interest or financial connection.

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF

ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION

N/A N/A N/A N/A

RELATIVES IN THE GOVERNMENT SERVICE

(Within the Fourth Degree of Consanguinity or Affinity. Include also Bilas, Balae and Inso)

I/We do not know of any relative/s in the government service)

NAME OF RELATIVE RELATIONSHIP POSITION NAME OF AGENCY/OFFICE AND ADDRESS

ANNELINE E. VENTUROZO SISTER EGT - II DEPED, DIVISION OF ZAMBALES

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 above-
enumerated 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: ______February 15, 2017______

(Signature of Declarant) (Signature of Co-Declarant/Spouse)

Government Issued ID: PRC Government Issued ID: PRC

ID No.: 0805411 ID No.: 1255209
Date Issued: 9/22/2003 Date Issued: 12/16/2016

SUBSCRIBED AND SWORN to before me this 15 day of February , 2017 affiant exhibiting to me the above-
stated government issued identification card.
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 Atty. ANTONIO C. CASANGKAPAN
Chief Administrative Officer
Administrative Services
(Person Administering Oath)

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