SWORN STATEMENT OF THE TRUE CURRENT AND FAIR MARKET VALUE OF REAL PROPERTIES

(Taxable or Exempt) as required under Section 202/203 of Republic Act No. 7160

I, _____________________________, of legal age,_______________, _______________ and with

postal address at _____________________________________________________, after having been duly
sworn to in accordance with law hereby depose and say:
THAT, I am the ___________________ (Owner / Administrator) of the following real properties (lands,
buildings, machineries or other improvements) located in the City of Lucena, Province of Quezon, owned by
___________________________________ of which the description and true current fair market value/s are as
follows:

A. LAND (Residential, Commercial, Industrial, Agricultural, Special)

Existing Classification Location of Total Current
Block Cadastral/ Area in
Tax Dec. Lot No. No. PLS No. Title No. has./sq. m.
(Res., Agr., Property and Fair
No. Com., etc.) (Barangay) Market Value

B. BUILDING AND OTHER STRUCTURES

Existing Total Floor Year Owner of Lot Location of Total Current
No. General Actual
Tax Dec. Area in Storey
Completed Use
Where Bldg. Property and Fair
No. Description is Located (Barangay)
(Sq. m.) / Occupied Market Value

C. MACHINERIES
Existing Date Original Cost of Location of Total Current
Value of
Tax Dec. Description Commenced
Acquisition Installation Property
Depreciation (Barangay)
and Fair
No. Acquired Operation Cost On Site Market Value

D. OTHER IMPROVEMENTS (Perennial Trees/Plants)

Existing No. of Annual No. of Trees/ Total Current and Fair
Kinds of
Tax Dec. Trees/ Has/ Product Per Has. & Ages Market Value
No. Trees/Plants Non-Productive
Productive Trees/Plants Productive Non-Productive

THAT, I am executing this sworn statement in compliance with Republic Act No. 7160.

IN WITNESS WHEREOF, I have hereunto affixed my signature this _______ day of _________________
at _________________________________________.

(Signature over printed name)

SUBSCRIBED AND SWORN to before me this __________________ affiant exhibiting his/her

Community Tax Certificate No. A- __________________ issued on _______________ at _________________,
Philippines.

MA. FLORENTINA JOSEPHINE M. EDERON

OIC, Office of the City Assessor

1) Include in this sworn statement only real property owned or administered by the affiant in one municipality of city; 2) Prepare three
(3) copies and after having been subscribed to by the affiant, submit the same to the Provincial, City, Municipal Deputy Assessor or Ex-
Officio Deputy Assessor of the province, City where the property is located; the original and duplicate to be retained by receiving office
and the triplicate to be returned to the affiant after receipt thereof has been duly acknowledge; 3) Write “NEW” under column “Existing
Tax Decl. No.” for property not previously declared; and 4) Original acquisition cost of Machinery.