Revi

sedasofJanuar
y2015
PerCSCResol
uti
onNo.1500088
Promul
gat
edonJanuary23,2015

SWORNSTATEMENTOFASSETS,
LIABI
LITI
ESANDNETWORTH
Asof_
___
___
___
___
___
___
___
___
___
___
_
(
Requi
redbyR.
A.6713)

Not
e:Husbandandwi
fewhoar
ebot
hpubl
i
cof
fi
cial
sandempl
oyeesmayf
il
ether
equi
redst
atement
sjoi
ntl
yorsepar
atel
y.
 Joi
ntFi
l
ing  Separ
ateFi
l
ing  NotAppl
i
cabl
e

DECLARANT: POSI
TION:
(
Fami
l
yName) (
Fir
stName) (
M.I
.) AGENCY/OFFI
CE:
ADDRESS: OFFI
CEADDRESS:

SPOUSE: POSI
TION:
(
Fami
l
yName) (
Fir
stName) (
M.I
.) AGENCY/OFFI
CE:
OFFI
CEADDRESS:

UNMARRI
EDCHI
LDRENBELOW EI
GHTEEN(
18)YEARSOFAGELI
VINGI
NDECLARANT’
SHOUSEHOLD

NAME DATEOFBI
RTH AGE

ASSETS,
LIABI
LITI
ESANDNETWORTH
(
Incl
udi
ngt
hoseofthespouseandunmarri
edchil
drenbel
owei
ght
een(
18)
year
sofagel i
vi
ngindecl
arant
’shousehol
d)
1.ASSETS
a. Real
Proper
ti
es*

DESCRI
PTI
ON KI
ND EXACT ASSESSED CURRENTFAI
R ACQUI
SITI
ON ACQUI
SITI
ONCOST
(
e.g.l
ot,
houseand (e.g.resi
dent
ial
, LOCATI
ON VALUE MARKETVALUE
l
ot,
condomi ni
um and commer cial
,i
ndust
ri
al,
improvements) agr
icult
uralandmixed (
Asf
oundi
ntheTaxDeclar
ati
onof
Real
Proper
ty)
YEAR MODE
use)

Subt
otal
:
b.Per
sonal
Prope
rti
es*

DESCRI
PTI
ON YEARACQUI
RED ACQUI
SI
TI
ON
COST/
AMOUNT

Subt
ota
l:

TOTALASSETS(
a+b)
:
*Addi
ti
onalsheet
/smaybeused,
ifnecessar
y.
Page1of_
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Page2of_
__
2. LI
ABI
LITI
ES*

NATURE NAMEOFCREDI
TORS OUTSTANDI
NGBALANCE

TOTALLI
ABI
LITI
ES:
NETWORTH:
Tot
alAsset
slessTot
alLi
abi
l
iti
es=
*Addi
ti
onalsheet
/smaybeused,
ifnecessar
y.

BUSI
NESSI
NTERESTSANDFI
NANCI
ALCONNECTI
ONS
(
ofDecl
arant/
Decl
arant
’sspouse/Unmar
ri
edChi
l
drenBel
owEi
ght
een(
18)year
sofAgeLi
vi
ngi
nDecl
arant
’sHousehol
d)
I
/Wedonothaveanybusi
nessi
nter
estorf
inanci
alconnect
ion.
NAMEOFENTITY/
BUSI
NESS BUSI
NESSADDRESS NATUREOFBUSINESSI
NTEREST DATEOFACQUISI
TIONOF
ENTERPRI
SE &/
ORFINANCI
ALCONNECTION I
NTERESTORCONNECTI
ON

RELATI
VESI
NTHEGOVERNMENTSERVI
CE
(
Wit
hint
heFour
thDegr
eeofConsangui
nit
yorAf
fi
nit
y.I
ncl
udeal
soBi
l
as,
Bal
aeandI
nso)
I
/Wedonotknowofanyr
elat
ive/
sint
hegover
nmentser
vice)
NAMEOFRELATI
VE RELATI
ONSHI
P POSI
TION NAMEOFAGENCY/
OFFI
CEANDADDRESS

Iherebycerti
fythatthese aretr
ueandcor rectst
atements ofmyassets,l
iabi
li
ti
es,networ
th,busi
ness
i
nterest
sandf inancial
connecti
ons,incl
udingthoseofmyspouseandunmar ri
edchi
l
drenbeloweight
een(
18)yearsof
agelivi
nginmyhousehol d,andt hattothebestofmyknowl edge,theabove-
enumer
atedarenamesofmyr el
ati
vesin
thegovernmentwi t
hinthefourt
hcivil
degreeofconsanguini
tyoraff
ini
ty.

Iherebyauthor
izetheOmbudsmanorhi s/
herdulyauthori
zedr epresent
ativ
et oobtai
nandsecurefr
om al
l
appropriat
e gov er
nmentagenci es,incl
udi
ng the BureauofI nt
ernalRevenue such document sthatmayshow my
assets,l i
abi
li
ties,networth,businessinter
ests and fi
nancialconnections,t oi ncl
ude thoseofmyspouseand
unmar r
iedchildrenbel
ow18y earsofageli
v i
ngwithmei nmyhousehol dcov eringprevi
ousyearstoincl
udet
heyearI
fi
rstassumedof f
icei
ngov er
nment .

Dat
e: _
___
___
___
___
___
___
___
___
___
__

(
Signat
ureofDecl
arant
) (
Signat
ureofCo-
Decl
arant
/Spouse)

Gover
nmentIssuedI
D: Gover
nmentIssuedI
D:
I
DNo.: I
DNo.:
Dat
eIssued: Dat
eIssued:

SUBSCRIBEDANDSWORN t
obef
oremet
his dayof ,af
fi
antexhi
bit
ingt
omet
hea
bov
e-s
tat
edgov
ernme
nt
i
ssuedi
dent
if
icat
ioncar
d.

_
___
___
___
___
___
___
___
___
___
___
___
___
__
(
Per
sonAdmi
nist
eri
ngOat
h)

Page3of_
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