SWORN STATEMENT OF ASSETS, LIABILITIES, AND NETWORTH

As of _____________
(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: ____________________ POSITION: ______________________

(Family Name) (First Name) (M. I.)
AGENCY/OFFICE: _, Tagbilaran City_____
ADDRESS: ____________________________
OFFICE ADDRESS : ___________________________________
_____________________________
____________________________________
SPOUSE: __________N/A____________________
POSITION: _______N/A_______________________________
(Family Name) (First Name) (M. I.)
AGENCY/OFFICE: ______________________ ______________
OFFICE ADDRESS: ______________________ ______________

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

NAME DATE OF BIRTH AGE

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 *
ASSESSED CURRENT FAIR ACQUISITION
DESCRIPTIO KIND LOCATION VALUE MARKET VALUE ACQUISITION
N (e.g. residential, COST
commercial, industrial,
(e.g. lot, house and (As found in the Tax Declaration of Real
agricultural and mixed
lot, condominium and use) Property) YEA MODE
improvements)
R
N/A

Subtotal: P _0_______
b. Personal and other Properties *
DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT
CAPITAL STOCK (MMGHHSC,TAGB. CITY) 2010-present 16,200.00
CASH IN BANK & ON HAND 2010-present 34,500.00
CFI-FIXED DEPOSIT (BOHOL BRANCH) 2011-present 14,000.00
FURNITURE & APPLIANCES Various years 63,000.00
JEWELRY & OTHER PERSONAL EFFECTS Various years 148,500.00

Subtotal: P 276,200.00 more or less

TOTAL ASSETS (a+b): P276,200.00 more or less

2. LIABILITES *
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
GSIS CONSOLIDATED LOAN GSIS 118,000.00
SALARY LOAN CEBU CFI COMMUNITY 60,000.00
COOPERATIVE (BOHOL BRANCH)
SALARY & EDUCATIONAL LOAN SCSLA, MANILA 68,000.00

TOTAL LIABILITIES: P 246,000.00 more or less

NET WORTH: Total Assets less Total Liabilities = P 30.200.00 more or less

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

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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 NATURE OF BUSINESS DATE OF ACQUISITION

ENTERPRISES BUSINESS ADDRESS INTEREST &/OR FINANCIAL OF INTEREST OR
CONNECTION CONNECTION

RELATIVES IN THE GOVERNMENT SERVICE

(Within the Fourth Degree of Consaguinity 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

- - -
-

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: April 16, 2018

_________________________________________ ____________________N/A__________________
(Signature of Declarant) (Signature of Co-Declarant/Spouse)

Government Issued ID: __________ Government Issued ID: __________________________

ID No.: _____CK3-1294__________ ID No.: __________________________
Date Issued: _____February 5, 2009____ Date Issued: _________________________

SUBSCRIBED AND SWORN to before me this 16th day of April, 2018 affiant exhibiting to me the above-stated government
issued identification card.

_______________________________
(Person Administering Oath)

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