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Revised as of January 2015

Per CSC Resolution No. 1500088


Promulgated on January 23, 2015

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH


As of _________DECEMBER 31, 2022__________
(Required by R.A. 6713)

Note: Husband and wife who are both public officials and employees may file the required statements jointly or separately.
 Joint Filing  Separate Filing  Not Applicable

DECLARANT: RIVERA JEFFERSON C. POSITION: TEACHER I


(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEPED CALOOCAN/CAYBIGA HIGH SCHOOL

ADDRESS: 6150 DUYAG ST MAPULANG LUPA OFFICE ADDRESS: PLEASANT VIEW SUBD. BAGBAGUIN
VALENZUELA CITY CALOOCAN CITY

SPOUSE: N/A POSITION: N/A


(Family Name) (First Name) (M.I.) AGENCY/OFFICE: N/A
OFFICE ADDRESS: N/A

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD

NAME DATE OF BIRTH AGE


CALYX JEORGE S. RIVERA SEPTEMBER 26, 2022 4 MONTHS

ASSETS, LIABILITIES AND NETWORTH


(Including those of the spouse and unmarried children below eighteen (18)
years of age living in declarant’s household)
1. ASSETS
a. Real Properties*

DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITIO


(e.g. lot, house and (e.g. residential, LOCATION VALUE MARKET VALUE N COST
lot, condominium commercial, industrial,
(As found in the Tax Declaration of
and improvements) agricultural and mixed YEAR MODE
use) Real Property)

LOT RESIDENTIAL REBECCA ST. IGAY SAN 429,000 1,078,000 2021 INHERITANC 1,078,000
JOSE DEL MONTE E
BULACAN

Subtotal: 1,078,000
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION


COST/AMOUNT

CHEVROLET SONIC 2015 2022 490,000.00


YAMAHA NMAX 2022 130,000.00
JEWELRIES/ APPLIANCES / CLOTHES 2022 130,000.00
BANK ACCOUNT 2022 93,000.00
Subtotal: 843,000.00

TOTAL ASSETS (a+b): P 1,921,000.


* Additional sheet/s may be used, if necessary.

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2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

LOAN CITY SAVING BANK 203,200.00


ATM LOAN EZ CREDIT 50,000.00
LOAN LEGAZPI BANK 220,000.00
LOAN GSIS 150,000.00
TOTAL LIABILITIES: 623,200.00
NET WORTH : Total Assets less Total Liabilities = P 1,297, 800.00
* Additional sheet/s may be used, if necessary.

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS


(of Declarant /Declarant’s spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarant’s Household)

 I/We do not have any business interest or financial connection .

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF


ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION
N/A N/A N/A N/A

RELATIVES IN THE GOVERNMENT SERVICE


(Within the Fourth Degree of Consanguinity or Affinity. Include also Bilas, Balae and Inso)

 I/We do not know of any relative/s in the government service)


NAME OF RELATIVE RELATIONSHIP POSITION NAME OF AGENCY/OFFICE AND ADDRESS
ROWENA C. BALANSAG AUNTIE TEACHER DEPED CALOOCAN / CAYBIGA HIGH SCHOOL

I hereby certify that these are true and correct statements of my assets, liabilities, net worth,
business interests and financial connections, including those of my spouse and unmarried children below
eighteen (18) years of age living in my household, and that to the best of my knowledge, the above-
enumerated are names of my relatives in the government within the fourth civil 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 Revenue such
documents that may show my assets, liabilities, net worth, business interests and financial connections,
to include those of my spouse and unmarried children below 18 years of age living with me in my
household covering previous years to include the year I first assumed office in government.

Date: _____February 1, 2023_____


N/A
JEFFERSON C RIVERA
(Signature of Declarant) (Signature of Co-Declarant/Spouse)

Government Issued ID: DRIVERS LISCENCE Government Issued ID:


ID No.: N25-01611265 ID No.:
Date Issued: August 04, 2020 Date Issued:

SUBSCRIBED AND SWORN to before me this day of , affiant exhibiting to me the above-stated
government issued identification card.

_______________________________________

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(Person Administering Oath)

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