Republic of the Philippines

Department of Education
Region VII, Central Visayas
Division of Carcar CITY
ASSETS, LIABILITIES AND NET WORTH
As of December 31, 2015
(Required by RA 6713)

Name:
(Surname) (First Name) (Middle Name)
Address: Office:
Office Address:
Spouse Name: Position/ Income:
(Surname) (First Name) (Middle Name) Office:

UNMARIED CHILDREN BELOW 18 YEARS OF

Name Date of Birth Name Date of Birth

A. ASSETS, LIABILITIES AND NET WORTH

I. ASSETS
A. Real Properties
Assessed Acquisition
Year Mode of Fair Cost
Kind Location
Acquired Acquisition Value Land Improve-
Real Etc. ments

Total
B. Personal and other Properties
Kind Year Acquired Acquisition Cost

Total
II. LIABILITIES ( Loan , Mortgage, etc.)
Nature Amount

Total:
NET WORTH (I.A + I.B) less total liabilities (II):
Note: Instruction at the back. Please use additional form if necessary
 C. BUSINESS INTEREST AND FINANCIAL CONNECTIONS

Do you have any business interest and other financial connection including those of your spouse and
unmarried children below 18 year of age living with your household?

( ) Yes ( ) No. If yes, give the particulars:

Position of Nature of bussiness Date of Acquisition

Name Firm or Address And/or or
Company Connections Connection

D. INDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

To the best of your knowledge, are you related within the fourth degree of consaguinity or of affainity
to anyone in the government?
( ) Yes ( ) No If Yes, give the particulars:

Name and Address

Name Position Relation
of Office

I hereby certify to the best of my knowledge and information, that these are true stament of my assets,
liabilities, net worth, business interest and financial connections including those of my spouse and unmarried
children below 18 years of age names of my relatives in the government as December 31 2010 as required
by in and accordance with Republic Act 8713

I hereby authorized, the Ombudsman or his authorized representative to obtain and secure from all
appropriate government agencies including the Bureau of Internal Revenue, such document that may show my
assets, liabilities, net worth, buseness intereset and financial connection, to include t hose 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
Signature

TIN:
Community Tax No. A B.
Issued at
Date Issued:

SUBSCRIBED AND SWORN to before me this _______ day of 201____

affiant exhibiting his/her Community Tax as indicated above.

Person Administering the Oath