(Form 1) 1994

Philippine Amusemen t & Gaming Corporation

A global corporation with a global mindset and a Filipino Heart

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

Spouse First Name Surname M.I. Office

Position

Unmarried children below 18 years of age

Date of Birth Name

A. ASSETS, LIABILITIES AND NET WORTH

a. Real Properties

community)

TOTAL b. Personal and Other Properties

TOTAL 2. LIABILITIES (Loans, Mortgage, etc. )

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

B. BUSINESS INTEREST AND FINANCIAL CONNECTIONS

Do you have any business interest and other financial connections including those of your spouse and unmarried children below 18 years of age living in your household ? ( ) yes ( ) no If yes give particulars;

C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

To the best of your knowledge, are you related within the fourth degree of consanguinity or of affinity to anyone working in the government ? ( ) yes ( ) no If yes, give particulars;

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. :

T.I.N. : Res. Cert. No. B : Issued At : Date Issued :

Res. Cert. No. A : Issued At : Date Issued :

SUBSCRIBED AND SWORN TO before me this Residence Tax Certificate as indicated above.

day of

,20

_, affiant exhibiting his

(Person Administering Oath)

/hrd 02/2010