_________________________________________ Unit/ Office SWORN STATEMENTS OF ASSETS AND LIABILITIES AND NET WORTH DISCLOSURE OF BUSSINESS INTERESTS AND

FINANCIAL CONNECTIONS, AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE As of ___________________________ (Required by RA No. 6713) Name: ___________________________________________________________________________________ (Surname/ First name/ M.I.) (Rank/ Serial No./ Br. of Svc) Date of Birth: ____________________________ Place of Birth: ____________________________________ Address: _________________________________________________________________________________ Date of Appointment/ CAD/ Enlistment: _______________________________________________________ Office Address: ____________________________________________________________________________ Position/ Designation: ______________________________________________________________________ Spouse Name: __________________________________ Position/ Office:____________________________ (Surname/ First name/ M.I.) Unmarried Children below 18 years of age Name Date of Birth Name of School/ Occupation

A. ASSETS, LIABILITIES AND NET WORTH 1. ASSETS a. Personal Properties: NATURE Mode Cash and Bank Deposits Receivables Investments (Bus, Stocks) Fur, Fixtures & Appliances Jewelry and Books Motor Vehicles Other Assets (Specify) Total ------------ P________________ b. Real Properties: Nature/ Location Mode of Acquisition House and Lot Agri Lands Apartments/ Bldgs Others (Spacify) Total ------------ P________________ TOTAL ASSETS (Personal & Real) ------------------- P________________ Acquisition Year Acquire d Repairs/ Improvements Prev Yrs. Current (Accum) Year Total Cost

Cost

Year Acquire d

Market Value

Acquisition Cost

Repairs/ Improvements Prev Yrs. Current Year

Total Cost

2. LIABILITIES CREDITORS Loans/ Banks/ Financial Institution Loans Personal NATURE YEAR Incurred TERM AMOUNT AMORTIZATION BALANCE

Other Accounts Payable

Total ---------------- P____________________

NET WORTH: Total Assets (1 & !b) Less Total Liabilities (2) --------------------P___________________

3. My family income and other sources of funds composed of salary, allowances, bonus, dividends, sale/ rentals of property, inheritance, financial aids, donations, etc., including those of my spouse and children below 18 years during the calendar year this statement is filed are as follows: COMPOSITION Filers Gross Compensation Income Spouse Gross Compensation Income Net Income from Bus Investments Professional Fees and/ or Similar Fees Financial Aids/ Assistance Inheritance Proceeds from Sale of Assets Other Income/ Source of fund NATURE SOURCE AMOUNT

Total ---------------- P____________________

4. The income tax I paid during the preceding calendar year to include income tax withheld for the current calendar year for which this statement is made amounted to P______________________ .

5. My/ our personal/ family expenses composed of food , clothing, schooling, medical, entertainment, insurance, interest paid of loans, educational plans, electrical/ water bills, rentals, other taxes etc. amount to P_______________________.

B. DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS Business interest and financial connection including those of my spouse and unmarried children below 18 years of age living in my household are the following: NAME NAME OF FIRM ADDRESS Nature of Business Interest and/ or Financial Connection Date of Acquisition/ Connection

C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE My relatives within the fourth degree of consanguinity or affinity/ to any one working in the government are as follows: Name Position Relationship Name/ Address of Office

I am making this statement in compliance with R.A. 6713. I am (check the appropriate statement): ________________ ________________ ________________ a. A new member/ employee of the AFP. b. Already a member/ employee of the AFP. c. Leaving the service.

I hereby certify to the best of my knowledge and information, that these are true statements of my assets, liabilities, networth, business interest, and financial connections, including those of my spouse and unmarried children below 18 years of age and names of relatives in the government service as of ____________________ as required by and in accordance with Republic Act 6713. Date: ____________________ ____________________________________ (Print Name/ Signature) Community Cert. No. _________________ Issued at ___________________________ Date Issued _________________________ TIN ___________________

SUBSCRIBED AND SWORN to before me this _____ th day of _______________________________ affiant exhibiting to me his/ her Community Tax Certificate as indicated above.

____________________________________ (Person Administering Oath)

____________________________________ (Duty & Unit Assignment)