SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of ________________________________
(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
DECLARANT: (Family Name) ADDRESS: (First Name)

Separate Filing

Not Applicable

(M.I.)

POSITION: AGENCY/OFFICE: OFFICE ADDRESS:

SPOUSE: (Family Name) (First Name) (M.I.)

POSITION: AGENCY/OFFICE: OFFICE ADDRESS:

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LI ING IN DECLARANT!S HOUSEHOLD
NAME DATE OF BIRTH AGE

ASSETS, LIABILITIES AND NETWORTH ( ncluding those of the spouse and unmarried children below eighteen (!"# years of age li$ing in declarant%s household# 1" ASSETS #" Re#$ P%o&e%t'e()
*IND
(e.g. reside"tial #ommer#ial i"dustrial agri#ultural a"d mi&ed use)

DESCRIPTION
(e.g. lot !ouse a"d lot #o"domi"ium a"d im$ro%eme"ts)

LOCATION

ASSESSED ALUE

CURRENT FAIR MAR*ET ALUE

AC+UISITION YEAR MODE

AC+UISITION COST

(As fou"d i" t!e 'a& (e#laratio" of Real )ro$erty)

S,-tot#$: -" Pe%(o.#$ P%o&e%t'e()

DESCRIPTION YEAR AC+UIRED AC+UISITION COST/AMOUNT

S,-tot#$ : TOTAL ASSETS (#/-): 0" LIABILITIES)

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

TOTAL LIABILITIES: NET WORTH : Tot#$ A((et( $e(( Tot#$ L'#-'$'t'e( 1 ) Additional sheet&s may be used' if necessary.

(age ! of )))

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

(of *eclarant &*eclarant%s spouse& +nmarried ,hildren -elow .ighteen (!"# years of Age /i$ing in *eclarant%s Household#

&0e do not ha$e any business interest or financial connection.

NAME OF ENTITY/BUSINESS ENTERPRISE BUSINESS ADDRESS NATURE OF BUSINESS INTEREST 2/OR FINANCIAL CONNECTION DATE OF AC+UISITION OF INTEREST OR CONNECTION

RELATI ES IN THE GO ERNMENT SER ICE

(0ithin the Fourth *egree of ,onsanguinity or Affinity. nclude also -ilas' -alae and nso#

&0e do not 1now of any relati$e&s in the go$ernment ser$ice#

NAME OF RELATI E RELATIONSHIP POSITION NAME OF AGENCY/OFFICE AND ADDRESS

I !ereby #ertify t!at t!ese are true a"d #orre#t stateme"ts of my assets liabilities "et *ort! busi"ess i"terests a"d fi"a"#ial #o""e#tio"s i"#ludi"g t!ose of my s$ouse a"d u"married #!ildre" belo* eig!tee" (1+) years of age li%i"g i" my !ouse!old a"d t!at to t!e best of my ,"o*ledge t!e abo%e-e"umerated are "ames of my relati%es i" t!e go%er"me"t *it!i" t!e fourt! #i%il degree of #o"sa"gui"ity or affi"ity. I !ereby aut!ori.e t!e /mbudsma" or !is0!er duly aut!ori.ed re$rese"tati%e to obtai" a"d se#ure from all a$$ro$riate go%er"me"t age"#ies i"#ludi"g t!e 1ureau of I"ter"al Re%e"ue su#! do#ume"ts t!at may s!o* my assets liabilities "et *ort! busi"ess i"terests a"d fi"a"#ial #o""e#tio"s to i"#lude t!ose of my s$ouse a"d u"married #!ildre" belo* 1+ years of age li%i"g *it! me i" my !ouse!old #o%eri"g $re%ious years to i"#lude t!e year I first assumed offi#e i" go%er"me"t. (ate2 ______________________________

(Signature of *eclarant# 3o%er"me"t Issued I(2 I( No.2 (ate Issued2

(Signature of ,o2*eclarant&Spouse# 3o%er"me"t Issued I(2 I( No.2 (ate Issued2

SUBSCRIBED AND SWORN to before me t!is ide"tifi#atio" #ard.

day of

affia"t e&!ibiti"g to me t!e abo%e-stated go%er"me"t issued

_______________________________________ ((erson Administering 3ath#

(age 4 of )))