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SWORN STATEMENT OF ASSETS, LIABILITIES, AND NET WORTH,

DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS,


AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE
December 31,
As of ____________________
(Required by 2016
Republic Act No. 6713)
Note: Husband and wife who are both public officials and employees may file the required statements jointly or separately.
/ /Joint Filling
/ /Separate Filling
/ /Not Applicable

DECLARANT: ____________________________________________
___________________________
(Family Name)
(First Name)
___________________________

Position:
(M.I)

Agency Office:

Office Address:
__________________________
Address: ________________________________________________
___________________________________
________________________________________________
Spouse: _________________________________________________ Position:
___________________________
(Family Name)
(First Name)
(M.I)
Agency Office:
___________________________
Office Address:
__________________________
________________________________
- - -

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN


DECLARANT HOUSEHOLD
1.
2.
3.
4.
5.
6.

NAME
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________

DATE OF BIRTH
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________

ASSETS, LIABILITIES AND NET WORTH

AGE
_________________
_________________
_________________
_________________
_________________
_________________

(Including those of the spouse and unmarried below eighteen (18) Years of age living in declarants
household)

1. ASSETS
a. Real Properties
DESCRIPTI
KINDS
LOCATI
Eg.
Residential,
ON
ON
commercial,
Eg. Lot house,
condominiums and
improvements)

agricultural, and
mixed use)

ASSESS CURREN
ED
T FAIR
VALUE
VALUE
As found in the Tax
Declaration of Real Property

ACQUISITION

YEAR

ACQUIS
ITION
COST

MODE

Subtotal: P
____________________
b. Personal and Other Properties
Kind
YEAR ACQUIRED

ACQUISITION COST

Subtotal:
P____________________
TOTAL ASSETS (a + b): P
____________________
2. LIABILITIES (Loans, Mortgages, etc.)
NATURE
NAME OF CREDITORS

AMOUNT

Total Liabilities: P

__________________

NETWORTH (Total Assets (1a + 1b) Less Total Liabilities (2)


______________________
Note: Pls. Use additional Form if necessary.

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

Do you have any business and other financial connection including these your spouse
and unmarried below 18 years of age living with you in your household / / Yes / / No,
If yes, give particulars:
NAME OF
BUSINES
NATURE OF BUSINESS
DATE OF
ENTITY/BUSINESS
S
INTEREST AND/OR
ACQUISITION
ENTERPRISES
FINANCIAL CONNECTIONS
OR
CONNECTION

RELATIVES IN THE GOVERNMENT SERVICE


(Within the fourth of consanguinity or Affinity. Include also Bilas, Bale and inso)
I/We do not have any relative/s in the government service.
NAME OF RELATIVE
RELATIONS
POSITION
NAME OF AGENCY OFFICE AND
HIP
ADDRESS

I hereby certify that those are true and correct statements of my assets, liabilities, net worth,
business interest and financial connections, including those of my spouse and unmarried children below
eighteen (18) years of age living in my household and that to the best of my knowledge, the aboveenumerated are names of any relatives in the government within the fourth civil degree of consanguinity
or affinity.
I hereby authorized 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 may
show my assets, liabilities, net worth, business interest and financial connections, to include those of my
spouse and unmarried children below 18 years of age living with me in my household covering past years
to include the year I first assumed office in government.

Date: _____________________________ 20______

___________________________________________
______________________________________________
Signature of Declarant
Declarant/spouse
Government Issued I.D: _______________________
________________________
I.D. No. ____________________________________
Issued on: __________________________________
___________________________________

Signature

Government

Issued

of

Co-

I.D:

I.D. No. _____________________________________


Issued
on:

SUBSCRIBED AND SWORN TO before me this ____________ day of _________________, affiant


exhibiting his/ her Residence Certificate was indicated.

___________________________________________
Personal Administering Oath