(Form 1) 1994

Philippine Amusement & 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 Posn./Gross Income

Surname First Name M.I. Office Philippine Amusement & Gaming Corporation
Address Office Address 1330 Roxas Boulevard, Ermita, Manila

Spouse Position
Surname First Name M.I. Office

Unmarried children below 18 years of age

Name Date of Birth

A. ASSETS, LIABILITIES AND NET WORTH

1. ASSETS
a. Real Properties
Nature of
Year Property Acquisition Cost
Mode of Assessed Current Fair Market
Kind Location Acquired (paraphernal
Acquisition Value Value Land,
conjugal or Improvements
community) Bldg. Etc.

TOTAL
b. Personal and Other Properties
Kind Year Acquired Acquisition Cost

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

TOTAL
NET WORTH ( Total Assets {1a + 1b} Less Total Liabilities {2} ) P0.00
*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;

Name of Firm / Nature of Business Interest Date of Acquisition or

Name Address
Company and/or Financial Connection Connection

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;

Name Position Relationship Name and Address of Office

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 :

Spouse's Signature over Printed Name Employee's Signature over Printed Name

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

SUBSCRIBED AND SWORN TO before me this _____ day of _________________,20______, affiant exhibiting his
Residence Tax Certificate as indicated above.

(Person Administering Oath)

/hrd
02/2010