Professional Documents
Culture Documents
AS OF _______________ NAME Position Title Office Address Spouse Name Position Title Office Address Unmarried Children Below 18 years of age
Name of Child
(Use additional sheets if necessary)
(Surname First Name Middle Name) (Surname First Name Middle Name)
Incom e
Date of Birth
A.
ASSETS AND LIABILITIES 1. Assets a. Real Properties (Use additional sheets if necessary)
Kind & Location Year Acquire d Mode of Acquisition Assessed Value Current Fair Market Value ACQUISITION COST Buildings Improv & Others e ments
TOTAL
Year Acquired
Acquisition Cost
TOTAL
Amount
TOTAL LIABILITIES
NETWORTH (Total Assets (1a+1b) Less Total Liabilities: B. DISCLOSURE OF CONNECTIONS BUSINESS INTERESTS AND FINANCIAL
Do you have interests and/or 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.
Name of Firm or Company Address of Firm or Company Nature of Business Interests and/or Financial Connections Date of Acquisition or Connection
Name
C.
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. Name Position Title Relationshi p Name & Address of Office
I HEREBY CERTIFY to the best of my knowledge and information that these are true statement of my assets, liabilities, net worth, business interests 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 RA 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 that my assets, liabilities, net worth, business interests and financial connections including those of my spouse and unmarried children below 18 years of age living with me in my household covering previous years to include the first year I assumed office in the government. Date: ,
Signature of Spouse
Signature of Employee
TIN
Comm. Tax Cert. No.
: : : :
: : : :
SUBSCRIBED AND SWORN TO before me this _____ day of _____________, __________, affiants exhibiting to me their Community Tax Certificates bearing the number indicated hereinabove. PERSON ADMINISTERING OATH