SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH

DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL

CONNECTIONS AND IDENTIFICATION OF RELATIVE
IN THE GOVERNMENT AS OF DECEMBER 31,_______
(Required by R.A. No. 6713)

Name: ____________________________________ Position/Income: _____________________________

(Surname) (First Name) (M.I.) Office:_____________________________________
Address:___________________________________ Office Address:______________________________
__________________________________________________________________________________________
Spouse Name:______________________________ Position: ____________________________________
(Surname) (First Name) (M.I.)

Unmarried children below 18 years of age.

Name DATE OF BIRTH

A. ASSETS, LIABILITIES AND NETWORTH

1. ASSETS
A. REAL PROPERTIES:
Current Acquisition Cost
Year Mode of Assessed Fair Land Improvements
Kind Location Acquired Acquisition Value Market Building
Value

Total_______________________

B. PERSONAL AND OTHER PROPERTIES:

Kind Year Acquired Acquisition Cost

Total ____________________

2. LIABILITIES (Loans, mortgages, etc.)

Nature Amount

Total _______________________

NETWORTH-ASSETS (1A + 1B) less Liabilities P________________ P ______________________

______________________
______________________

Note: Instructions at the back. Please use another form if necessary.

C. BUSINESS INTEREST AND FINANCIAL CONNECTIONS

B. Do you have any business interest and other financial connection including those of your spouse and
Unmarried children below 16 years of age living with you in your household?
Yes ________ No ________ If yes, give particulars:

Name of Firm Address Nature of Business Date of

Name Company and/or Financial Acquisition or
Connection Connection

D. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

To the best of your knowledge, are you related with the fourth degree of consanguinity or of affinity to anyone
working in the government?
Yes ______ No ______ If yes, give particulars.
Name Position Relationship Name/Address of
Office

I HEREBY CERTIFY to the best of my knowledge and information, that these are true statements of
my assets, liabilities, networth, business interest and financial connection, including those of my spouse and
unmarried children below 18, years of age and names of my relatives in the government as of December 31,
________ as required by and in accordance with Republic Act 6713.

I hereby authorize the Ombudsman or his duly authorized representative to obtain and secure from all
appropriate government agencies, including the Bureau of Internal Revenue such documents 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 1 first assumed office in government.

Date _______________________ _________________________________

Signature of Employee
Res. Cert. No. _______________
Issued at ___________________
Date Issued _________________ TIN:_____________________________

SUBSCRIBED AND SWORN TO before me this ___________ day of _______________________

200____, at ____________________________________.

__________________________________
Person Administering Oath