(ito naman ang format pag mag additional sheet ka)

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 31 December 2023
(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:
Dalisay Cardo B CG SN1 /POIC Admin Department
(Family Name) (First Name) (M.I.) DOTr-PCG/CGDNM
ADDRESS: Lower Kabatan, Vincenzo Sagun, OFFICE ADDRESS: 1280 Corrales Extension Port Area
Zamboanga del Sur Brgy Puntod, Cagayan De Oro City
Misamis Oriental
SPOUSE: Dalisay Carla L POSITION: House Wife (pag walang trabaho)
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: N/A
OFFICE ADDRESS: N/A
N/A

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NAME DATE OF BIRTH AGE
N/A N/A N/A
N/A N/A N/A
N/A N/A N/A
N/A N/A N/A

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 ACQUISITION

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

Lot Agriculture Corrales Ext., Macabalan, (makikita sa Tax (makikita sa Tax

2021 (Cash/ Php
Cagayan de Oro, Misamis Declaration Declaration Installment/
Oriental Property) Property) hereditary/ 1,500,000.00
Donation)
N/A N/A N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A N/A N/A
Subtotal: Php
1,500,000.00
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

Cellphone 2019-2022 Php 100,000.00

Clothing 2022-2022 Php 40,000.00
Shoes 2022 Php 10,000.00
Jewelry 2021-2022 Php 118,000.00
Subtotal : Php 268,000.00

TOTAL ASSETS (a+b): Php 1,768,000.00

* Additional sheet/s may be used, if necessary. (dapat meron peso sign at decimal)

Page 1 of 3
 (ito naman ang format pag mag additional sheet ka)

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 31 December 2023
(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:
Dalisay Cardo B CG SN1 /POIC Admin Department
(Family Name) (First Name) (M.I.) DOTr-PCG/CGDNM
ADDRESS: Lower Kabatan, Vincenzo Sagun, OFFICE ADDRESS: 1280 Corrales Extension Port Area
Zamboanga del Sur Brgy Puntod, Cagayan De Oro City
Misamis Oriental
SPOUSE: Dalisay Carla L POSITION: House Wife (pag walang trabaho)
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: N/A
OFFICE ADDRESS: N/A
N/A

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 ACQUISITION COST

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

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A N/A N/A
N/A N/A N/A N/A N/A N/A N/A N/A

b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

Cellphone 2019-2022 Php 100,000.00

Clothing 2022-2022 Php 40,000.00
N/A N/A N/A

2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

ACDI Salary Loan Php 7,005.85

ACDI Car Loan Php 246,605.92
Land Bank Salary Loan Php 185,000.00
N/A N/A N/A

Page 2 of 3
 (ito naman ang format pag mag additional sheet ka)
2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

ACDI Salary Loan Php 7,005.85

ACDI Car Loan Php 246,605.92
Land Bank Salary Loan Php 185,000.00
N/A N/A N/A
TOTAL LIABILITIES: Php 438,611.77
NET WORTH: Total Assets less Total Liabilities = Php 1,329,388.23

* Additional sheet/s may be used, if necessary (pagnegative, lagayan ng negative sign)

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 INTEREST DATE OF ACQUISITION OF

ENTERPRISE &/OR FINANCIAL CONNECTION INTEREST OR CONNECTION
N/A N/A N/A N/A
N/A N/A N/A N/A
N/A N/A N/A N/A
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
Cardo D Dalisay Sr. Father Teacher 3 DepEd/ Binuay Dimataling, Zamboanga del Sur
Juana D Dalisay Mother Admin Officer II DOH-MRH/Margosatubig, Zambpanga del Sur
Juanita Dalisay Sister Fire Officer 1 DILG-BFP/Margosatubig, Zambpanga del Sur
N/A N/A N/A N/A

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: 23 December 2023

(meron dapat ID Nr at Pirma yung asawa mo)

(Signature of Declarant) (Signature of Co-Declarant/Spouse)

Government Issued ID: Philippine Coast Guard ID Government Issued ID: Philippine Coast Guard ID
ID No.: CG23-NO-123456 ID No.: CG23-DD-1234589
Date Issued: 20 January 2023 Date Issued: 15 February 2023

SUBSCRIBED AND SWORN to before me this 23rd day of January 2023, affiant exhibiting to me the above-stated government
issued identification card.

CG LTJG KATHERINE GIFT INDOG

(Person Administering Oath)
(Ang pipirma si Station Commander pag nsa Station
or Substation/ ang pipirma ky station commander ay
si ADMIN)

Page 3 of 3
(may pages lahat ng SALN)
(ito naman ang format pag mag additional sheet ka)