SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH

DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS

AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE
As of December 31, 2020
(Required by R.A. 6713)
Name: Position/Income: Teacher I
(Surname) (First Name) (M.I.) Office: Schools Division of Ifugao
Address: Office Address: Lagawe, Ifugao
Spouse Name: N/A Position:
(Surname) (First Name) (M.I.) Office:

Unmarried Children below 18 years of age

Name Date of Birth

A. ASSETS, LIABILITIES AND NETWORTH

1. ASSETS
a. Real Properties
Acquisition Cost
Current Fair
Year Mode of Nature of Assessed
Kind Location Market Land; Building,
Acquired Acquisition Property Value Improvement
Value etc.

Total:
b. Personal and other Properties
Kind Year Acquired Acquisition Cost

Total:
2. LIABILITIES(Loans, Mortages, etc)
Nature Name of Creditors Amount

NETWORTH (total Assets(1a+1b) Less Total

Liabilites (2)
 (Note: Please use additional; forms/sheets if
neccesarry. Also, please repoduce this form back to
back
B. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
Do you have any business interest and other financial connections including those of your spouse and unmarried
children below 18 years of age living with you in your ousehold?

[ ] Yes [ / ] No If yes, give particulars:

Nature of Business Interest

Name of Firm/ Date of Acquisition or
Name Address and/or Financial
Company Connection
Connection
N/A
N/A
N/A
N/A
C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

To the best of your knowledge, are you related with the fourth degree of consanguinity or of affinity to everyone
working in the government?

[ ] Yes [/ ] No If yes, give particulars:

Name Position Relationship Name/Address of Office

I hereby certify that these are true and correct statements of my assets, liabilities, net worth, business interest,
and financials connections and that to the best of my knowledge, the above enumerated are the names of my
relatives in the government within the fourth 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 Revenues such documents that may show such
assets, liabilities, net worth, business interests, and financial connections to include the years I first assumed office
in government.

Date:

(Signature of Employee)
TIN:
Com. Cert. No. 16882082

Issued at: LAGAWE, IFUGAO

Issued on: January 15, 2021
SUBSCRIBED AND SWORN to before me on this ___ day of October 2021 affiant exhibiting her

RESIDENCE TAX CERTIFICATE as indicated above.