SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS

AS OF _______________ NAME Position Title Office Address Spouse Name Position Title Office Address Unmarried Children Below 18 years of age
Name of Child
(Use additional sheets if necessary)
(Surname First Name Middle Name) (Surname First Name Middle Name)

Incom e

Date of Birth

A.

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

TOTAL

b. Personal and Other Properties

Kind

(Use additional sheets if necessary)

Year Acquired

Acquisition Cost

TOTAL

TOTAL ASSETS: 2. Liabilities (Loans, Mortgages, etc.)

Nature
[Use additional sheets if necessary]

Amount

TOTAL LIABILITIES

NETWORTH (Total Assets (1a+1b) Less Total Liabilities: B. DISCLOSURE OF CONNECTIONS BUSINESS INTERESTS AND FINANCIAL

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.
Name of Firm or Company Address of Firm or Company Nature of Business Interests and/or Financial Connections Date of Acquisition or Connection

Name

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 p Name & Address of Office

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 __________ 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
Comm. Tax Cert. No.

: : : :

Issued at Date Issued

TIN Comm. Tax Cert. No. Issued at 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