SS #

SWORN STATEMENT OF THE TRUE VALUE OF REAL PROPERTIES PURSUANT TO R.A. 7160
(TAXABLE OR EXEMPT)
1. , of legal age and with postal address at after having been duly
sworn to citizenship in accordance with law, depose and say:

That I am the of the following real properties, which are (declared or undeclared, newly acquired/
construction/installed/undergone/renovation/alteration/structural change or additional improvement) located in City/ Municipality of

, Province , owned by in which the description and

true market value/s are as follows:

A. Lands(Residential, Commercial, Industrial, Agricultural, Mineral, Timberland or Special)

Existing
Lot Blk. Cad/PLS Area
TD No./ ACTUAL USE LOCATION OF PROPERTY True Market Value
No. No. No. Ha./Sq.M.
ARP No./PIN

B. Building(s) and other Structures:

Existing FLOOR AREA Structural ERECTED AT

No. of Actual LOCATION OF PROPERTY True Market
TD No./ Previously Newly Character- Lot
Storey Lot Owner Use (No./St./Brgy./Dist.) Value
ARP No./PIN Declared Declared istics No.
C. Machineries

Existing DATE INSTALLED AT True

TD NO./ General Actual LOCATION OF PROPERT Acquisition
Market
ARP Description Started Lot Use (No./St./Brgy./Dist.) Cost
Acquired Lot Owner Value
No./PIN Operation No.

D. Perennial Trees/ Plants

Existing Annual
NO. OF TREE Produ- STANDING AT TRUE MARKET VALUE
TD NO./ LOCATION OF PROPERT
KIND ction
ARP Fruit Non-Fruit Lot (No./St./Brgy./Dist.) Non-Fruit
No./PIN Bearing
Lot Owner Fruit Bearing
Bearing No. Bearing

2. That I am executing this own declaration pursuant to Section 202 and/or Section 203 of the local Government Code of 1991.

IN WITNESS WHEREOF, I have hereunto affixed my signature this day of , 20 at ,

(if thumb marked, requires signature of two(2) witnesses:

(Signature of Affiant)

T.A.N. :
(Witness) (Witness)
SUBSCRIBED AND SWORN to before me this of , 20 , affiant exhibiting his/her community Tax Certificate No.
Issued on at

(Signature of Administering Officer)