Revised as of January 2015

Per CSC Resolution No. 1500088

Promulgated on January 23, 2015

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of
(Additional sheet/s for the exclusive properties of the declarant’s spouse and unmarried children
Below eighteen (18) years of age living in declarant’s household)

NAME: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:

ASSETS, LIABILITIES AND NETWORTH

1. ASSETS

a. Real Properties

KIND CURRENT FAIR

DESCRIPTION ASSESSED
(e.g. residential, MARKET ACQUISITION ACQUISITION
(e.g. lot, house and commercial, EXACT LOCATION VALUE
lot, condominium industrial, VALUE COST
and improvements) agricultural and (As found in the Tax Declaration of
mixed use) Real Property) YEAR MODE

b. Personal Properties

ACQUISITION
DESCRIPTION YEAR ACQUIRED
COST/AMOUNT

2. LIABILITIES

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

NATURE OF BUSINESS
NAME OF ENTITY/BUSINESS DATE OF ACQUISITION OF
BUSINESS ADDRESS INTEREST&/ OR FINANCIAL
ENTERPRISE INTEREST OR CONNECTION
CONNECTION

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 Revised as of January 2015
Per CSC Resolution No. 1500088
Promulgated on January 23, 2015

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of
(Additional sheet/s for the declarant)

NAME: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:

ASSETS, LIABILITIES AND NETWORTH

1. ASSETS

a. Real Properties

KIND CURRENT FAIR

DESCRIPTION ASSESSED
(e.g. residential, MARKET ACQUISITION ACQUISITION
(e.g. lot, house and commercial, EXACT LOCATION VALUE
lot, condominium industrial, VALUE COST
and improvements) agricultural and (As found in the Tax Declaration of
mixed use) Real Property) YEAR MODE

b. Personal Properties

ACQUISITION
DESCRIPTION YEAR ACQUIRED
COST/AMOUNT

2. LIABILITIES

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

NATURE OF BUSINESS
NAME OF ENTITY/BUSINESS DATE OF ACQUISITION OF
BUSINESS ADDRESS INTEREST&/ OR FINANCIAL
ENTERPRISE INTEREST OR CONNECTION
CONNECTION

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