FINANCIAL CONNECTIONS, AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE As of ___________________________ (Required by RA No. 6713) Name: ___________________________________________________________________________________ (Surname/ First name/ M.I.) (Rank/ Serial No./ Br. of Svc) Date of Birth: ____________________________ Place of Birth: ____________________________________ Address: _________________________________________________________________________________ Date of Appointment/ CAD/ Enlistment: _______________________________________________________ Office Address: ____________________________________________________________________________ Position/ Designation: ______________________________________________________________________ Spouse Name: __________________________________ Position/ Office:____________________________ (Surname/ First name/ M.I.) Unmarried Children below 18 years of age Name Date of Birth Name of School/ Occupation

A. ASSETS, LIABILITIES AND NET WORTH 1. ASSETS a. Personal Properties: NATURE Mode Cash and Bank Deposits Receivables Investments (Bus, Stocks) Fur, Fixtures & Appliances Jewelry and Books Motor Vehicles Other Assets (Specify) Total ------------ P________________ b. Real Properties: Nature/ Location Mode of Acquisition House and Lot Agri Lands Apartments/ Bldgs Others (Spacify) Total ------------ P________________ TOTAL ASSETS (Personal & Real) ------------------- P________________ Acquisition Year Acquire d Repairs/ Improvements Prev Yrs. Current (Accum) Year Total Cost


Year Acquire d

Market Value

Acquisition Cost

Repairs/ Improvements Prev Yrs. Current Year

Total Cost

My/ our personal/ family expenses composed of food . electrical/ water bills. The income tax I paid during the preceding calendar year to include income tax withheld for the current calendar year for which this statement is made amounted to P______________________ . clothing. bonus. My family income and other sources of funds composed of salary. 5. rentals. amount to P_______________________. financial aids. inheritance. sale/ rentals of property. including those of my spouse and children below 18 years during the calendar year this statement is filed are as follows: COMPOSITION Filer’s Gross Compensation Income Spouse Gross Compensation Income Net Income from Bus Investments Professional Fees and/ or Similar Fees Financial Aids/ Assistance Inheritance Proceeds from Sale of Assets Other Income/ Source of fund NATURE SOURCE AMOUNT Total ---------------. . medical. entertainment.P____________________ NET WORTH: Total Assets (1 & !b) Less Total Liabilities (2) --------------------P___________________ 3. schooling. donations.2. dividends.. allowances. interest paid of loans. etc. insurance. other taxes etc.P____________________ 4. LIABILITIES CREDITORS Loans/ Banks/ Financial Institution Loans Personal NATURE YEAR Incurred TERM AMOUNT AMORTIZATION BALANCE Other Accounts Payable Total ---------------. educational plans.

_________________ Issued at ___________________________ Date Issued _________________________ TIN ___________________ SUBSCRIBED AND SWORN to before me this _____ th day of _______________________________ affiant exhibiting to me his/ her Community Tax Certificate as indicated above. A new member/ employee of the AFP. Leaving the service. Date: ____________________ ____________________________________ (Print Name/ Signature) Community Cert.B. c. networth. No. I am (check the appropriate statement): ________________ ________________ ________________ a. I hereby certify to the best of my knowledge and information. that these are true statements of my assets. liabilities. and financial connections. including those of my spouse and unmarried children below 18 years of age and names of relatives in the government service as of ____________________ as required by and in accordance with Republic Act 6713. business interest. 6713. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE My relatives within the fourth degree of consanguinity or affinity/ to any one working in the government are as follows: Name Position Relationship Name/ Address of Office I am making this statement in compliance with R.A. DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS Business interest and financial connection including those of my spouse and unmarried children below 18 years of age living in my household are the following: NAME NAME OF FIRM ADDRESS Nature of Business Interest and/ or Financial Connection Date of Acquisition/ Connection C. ____________________________________ (Person Administering Oath) ____________________________________ (Duty & Unit Assignment) . Already a member/ employee of the AFP. b.

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