Professional Documents
Culture Documents
SWORN STATEMENT OF ASSETS, LIABILITIES, NET WORTH, DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS, AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE as of December 31, 20
(Required by R. A. No.6713)
Name Surname First Name M.I. Office Address Office Address 1330 Roxas Boulevard, Ermit a, Manila Posn./Gross Income Phili ppine Am usement & Gam ing Corporation
Position
a. Real Properties
community)
TOTAL
NET WORTH ( Total Assets {1a + 1b} Less Total Liabilities {2} )
*Note: Instruction at the Back. Please use additional forms if necessary
PAGCOR HOUSE 1330 Roxas Boulevard Ermita Metro Manila ZIP Code 1000 Telephone (632) 521-1542 Connecting All Departments FAX (632) 522-2969
I hereby certify to the best of my knowledge and information that these are true statements of my assets ,liabilities, net worth, business interest and financial connections, including those of my spouse and unmarried children below 18 years of age and names of my relatives in the government as of , , as required by and in accordance with Republic Act 6713.
I hereby authorized the Ombudsman or his 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 interest 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 the government.
Date :
Employee's Signature over Printed Name Spouse's Signature over Printed Name
T.I.N. :
SUBSCRIBED AND SWORN TO before me this Residence Tax Certificate as indicated above.
day of
,20
/hrd 02/2010