SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH

DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL

CONNECTIONS
AS OF DECEMBER 31, 2009

NAME (Surname First Name Middle Name)

Position Title Incom
e
Office
Address
Spouse Name (Surname First Name Middle Name)
Position Title
Office
Address

Unmarried Children Below 18 years of age (Use additional sheets if necessary)

Name of Child Date of Birth

A. ASSETS AND LIABILITIES

1. Assets
a. Real Properties (Use additional sheets if necessary)
ACQUISITION COST
Year
Kind & Mode of Assessed Current Fair Buildings Improv
Acquire
Location Acquisition Value Market Value & Others e
d
ments

TOTAL

b. Personal and Other Properties (Use additional sheets if necessary)

Kind Year Acquired Acquisition Cost

TOTAL
TOTAL ASSETS:
2. Liabilities (Loans, Mortgages, etc.) [Use additional sheets if necessary]
Nature Amount

TOTAL LIABILITIES
NETWORTH (Total Assets (1a+1b) Less Total Liabilities:

B. DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL

CONNECTIONS
Do you have interests and/or financial connections including those of your
spouse and unmarried children below 18 years of age living with you in your
household? Yes No If
Yes, give
particulars.

Nature of Business Date of

Name of Firm or Address of Firm or Interests and/or Acquisition or
Name Company Company Financial Connection
Connections

C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

To the best of your knowledge, are you related within the fourth degree of
consanguinity or affinity to anyone working in the government? Yes
No. If
Yes, give
particulars.

Name Position Title Relationshi Name & Address of Office

p

I HEREBY CERTIFY to the best of my knowledge and information that these

are true statement of my assets, liabilities, net worth, business interests and
financial connections including those of my spouse and unmarried children below 18
years of age and names of my relatives in the government as of 31 December 2009
as required by and in accordance with RA 6713.

I HEREBY AUTHORIZE the Ombudsman or his duly authorized representative

to obtain and secure from all appropriate government agencies including the
Bureau of Internal Revenue, such documents that my assets, liabilities, net worth,
business interests and financial connections including those of my spouse and
unmarried children below 18 years of age living with me in my household covering
previous years to include the first year I assumed office in the government.

Date: ,

Signature of Spouse Signature of Employee

TIN : TIN :
Comm. Tax Cert. : Comm. Tax Cert. :
No. No.
Issued at : Issued at :
Date Issued : Date Issued :
 SUBSCRIBED AND SWORN TO before me this _____ day of
_____________, __________, affiants exhibiting to me their Community Tax
Certificates bearing the number indicated hereinabove.

PERSON ADMINISTERING
OATH