Você está na página 1de 5

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET

WORTH
As of _______________________
(Required by R.A. 6713)
Note: Husband and wife who are both public officials and employees may files the
required statements jointly or separately

Joint Filing
Not Applicable

Separate

Filing

DECLARANT: __________________________________________________
POSITION:__________________________________
(Family Name)
________________________

(First Name)

(M.I)

AGENCY/ OFFICE:

ADDRESS: _____________________________________________________ OFFICE


ADDRESS: _________________________
_____________________________________________________
________________________
SPOUSE: ________________________________________________________POSITION:
__________________________________
(Family Name)
________________________

(First Name)

(M.I)

AGENCY/ OFFICE:

OFFICE ADDRESS: ________________________

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN


DECLARANTS HOUSEHOLD
NAME
AGE
__________________________________________________
_______________________________
______________________

DATE OF BIRTH

__________________________________________________
_______________________________
______________________
__________________________________________________
_______________________________
______________________
__________________________________________________
________________________________ ______________________

ASSETS, LIABILITIES AND NETWORTH


(Including those of the spouse and unmarried children below eighteen (18) years of
age living in declarants household)
1. ASSETS

DESCRIPTI
ON
(e.g. lot,
house and
lot,
condominiu
m and
improvemen
ts)

KIND
(e.g.
residential
,
commerci
al,
industrial,
agricultur
al and
mixed
use)

LOCATIO
N

ASSESS
ED
VALUE

CURRENT
FAIR
MARKET
VALUE

(As found in the Tax


Declaration of Real
Property)

ACQUISITION

YEAR

MODE

a. Real Properties*

b. Personal Properties*
DESCRIPTION

YEAR ACQUIRED

ACQUISITION
COST

ACQUISITIO
COST

Subtotal: ___________________________________
TOTAL ASSETS (a+b): ___________________________________
2. LIABILITIES*
NATURE

NAME OF CREDITORS

OUTSTANDING
BALANCE

TOTAL LIABILITIES: ______________________________


NET WORTH:

Total Assets less Total Liabilities =


______________________________

*Additional sheet/s may be used, if necessary.


Page 1 of _____
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(of Declarants/ Declarants spouse/ Unmarried Children Below Eighteen (18)
years of Age Living in Declarants Household)
I/ We do not have any business interest of financial connection.
NAME OF
ENTITY/
BUSINESS
ENTERPRISE

BUSINESS
ADDRESS

NATURE OFF
BUSINESS
INTEREST &/OR
FINANCIAL
CONNECTION

DATE OF
ACQUISTION OF
INTEREST OR
CONNECTION

RELATIVES IN THE GOVERNMENT SERVICE


(Within the Fourth Degree of Consaguinity of Affinty. Include also Bilas, Balae and
Inso)

I/We do not know of any relative/s in the government service


NAME OF
RELATIVE

RELATIONSHIP

POSITION

NAME OF AGENCY/ OFFICE AND


ADDRESS

I hereby certify that these are true and correct statements of my


assets, liabilities, net worth, business interests and financial connections,
including those of my spouse and unmarried children eighteen (18) years of
age living in my household, and that to the best of my knowledge, the aboveenumerated are names of my relatives in the government within the fourth
civil degree of consanguinity of affinity.
I hereby authorize the Ombudsman or his/her duly authorized
representative to obtain and secure from all appropriate government
agencies, including the Bureau of Internal Revenue such documents that may
show mu assets, liabilities, net worth, 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 government.
Date: ___________________________
________________________________________________
_______________________________________________
(Signature of Declarant)
Declarant/Spouse)
Government Issued ID: ______________________
ID: ___________________
ID No.:
_______________________
___________________
Date Issued:
_______________________
___________________

(Signature of Co-

Government Issued
ID No.:
Date Issued:

SUBSCRIBED AND SWORN to before me this _____ day of ___________,


affiant exhibiting to me the above-stated government issued identification
card.
______________________________________
(Person Administering Oath)

Page 2 of ______