<NAME OF AGENCY>

<NAME OF SCHOOL/DISTRICT>
Summary List of Filers
Statements of Assets, Liabilities and Net Worth
Calendar Year 20_____

NAME OF EMPLOYEE (in alphabetical order)

No. TIN Position Net Worth
Last Name First Name Middle Name

1
2
3
4
5
6
7
8
9
10
Total Number of Filers: _______
Total Number of Personnel Complement: _______

Prepared by:

(Name and Signature) (N

District/School Review Committee District/

Position: ____________________
Email Address: _______________
Contact No.: _________________
Date: _______________

Noted by:

(Name and Signature)

School Head/District In-Charge
Chairman - District/School Review Committee

Position: ____________________
Email Address: _______________
Contact No. : _________________
Date: _______________
 Attachment A

NCY>
TRICT>
ers
and Net Worth
___

If Spouse is with the government service, Please check (√)

PLEASE INDICATE if
NAME OF SPOUSE/EMPLOYER/ADDRESS Joint Filing

(Name and Signature)

District/School Review Committee

Position: ____________________
Email Address: _______________
Contact No. : _________________
Date: _______________

Signature)
trict In-Charge
ool Review Committee