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 ______December 31, 2020_______
(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  Separate Filing  Not Applicable please check

DECLARANT: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: Please use
ADDRESS: OFFICE ADDRESS: Your School address
Always use updated
Surname
SPOUSE: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:
OFFICE ADDRESS:

*Always put N/A if it does not require your information.

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NAME DATE OF BIRTH AGE
Please do not include children ages 19 y/o
above unless the children is with disability

ASSETS, LIABILITIES AND NETWORTH

(Including those of the spouse and unmarried children below eighteen (18)
years of age living in declarant’s household)
1. ASSETS
a. Real Properties*

DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION

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

Please
use
LOT Please indicate Inheritance

Exact location Usufruct zero cost

With barangay & Grant
municipality Donation
SALE With
Purchased Amount
House constructed

Subtotal: Php
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

Clothing and accessories Please indicate the YEAR Php

Electronic Gadgets and Equipment Purchased the said
Appliances and Furnitures description
Kitchen Wares
Jewelry
Savings
GENSET
Books
Subtotal : Php
TOTAL ASSETS (a+b): Php
* Additional sheet/s may be used, if necessary.
Always put peso sign

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 2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

Use SALARY LOAN, EMERGENCY PAG-IBIG, GSIS, MTMAS, or any BANKS Php
LOAN, GFAL, PROVIDENT LOAN,
PERSONAL LOAN, MPL

TOTAL LIABILITIES: Php

NET WORTH : Total Assets less Total Liabilities = Php
* Additional sheet/s may be used, if necessary.
*Based your liabilities using your PAYSLIP; computation will be sent in the other sheet

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

(of Declarant /Declarant’s spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarant’s Household)

√ I/We do not have any business interest or financial connection .

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF

ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION
N/A
*If this part is applicable to you just fill-out this and don’t put check.

RELATIVES IN THE GOVERNMENT SERVICE

(Within the Fourth Degree of Consanguinity or Affinity. Include also Bilas, Balae and Inso)

√ I/We do not know of any relative/s in the government service)

NAME OF RELATIVE RELATIONSHIP POSITION NAME OF AGENCY/OFFICE AND ADDRESS
N/A
*If this part is applicable to you just fill-out this and don’t put check.

I hereby certify that these are true and correct statements of my assets, liabilities, net worth,
business interests 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 above-
enumerated are names of my relatives in the government within the fourth civil degree of consanguinity or
affinity.

I hereby authorize the Ombudsman or his/her 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 interests and financial connections,
to include those of my spouse and unmarried children below 18 years of age living with me in my
household covering previous years to include the year I first assumed office in government.

Date: ______________________________ date you accomplished this form Fill-out if Joint Filling

N/A
(Signature of Declarant) (Signature of Co-Declarant/Spouse)

Government Issued ID: Government Issued ID:

ID No.: ID No.: N/A
Date Issued: Date Issued:

SUBSCRIBED AND SWORN to before me this day of , affiant exhibiting to me the above-stated
government issued identification card.

ANTERO S. BUIZA
Administrative Officer V

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 (Person Administering Oath)

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