Professional Documents
Culture Documents
1. ASSETS
a. Real Properties
ACQUISITION COST
Land,
NATURE OF B
CURRENT
PROPERTY ui
YEAR MODE OF ASSESSED FAIR
KIND LOCATION (paraphernal, ld
ACQUIRED ACQUISITION VALUE MARKET Improvements
conjugal, or in
VALUE
community) g,
et
c.
N N
N / /
N/A N/A N/A N/A /A N/A N/A A 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 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
Total P ___ N/A _______
b. Personal and Other Properties
KIND/S YEAR ACQUIRED ACQUISITION COST
Total P ___30,000_______
NETWORTH [Total Assets (1a + 1b) less Total Liabilities (2)] Total P ___-17,000__________
Note; Please use additional forms/sheets if necessary.
B. BUSINESS INTERESTS 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 with you in your household? Yes No
If yes, give particulars:
To the best of your knowledge, are you related within the fourth degree of consanguinity or 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, networth, business interest and financial connections including those of my spouse and unmarried
children below 18 years of age and names of relatives in the governments as of December 31, 19__, as required
by and in accordance with Republic Act 6713.
I hereby authorize the Ombudsman or his authorized representatives to obtain and secure from all
appropriate government agencies, including the Bureau of Internal Revenue, such documents that may show my
assets, liabilities, networth, 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 the government.
Com. Cert. No. ___ N/A ___________ Com. Cert. No. _30225562_____________
Issued at: _____ N/A ______________ Issued at: _Mariveles, Bataan___________
Issued on: _____ N/A ______________ Issued on: _March 31, 2011____________