Revised as of January 2015

Per CSC Resolution No. 1500088

Promulgated on January 23, 2015

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 file the required statements jointly or separately.
Joint Filing Separate Filing Not Applicable
DECLARANT: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:
OFFICE ADDRESS:
ADDRESS:

SPOUSE: POSITION:
(Family Name ) (First Name) (M.I.) AGENCY/OFFICE:
OFFICE ADDRESS:

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT'S HOUSEHOLD
NAME DATE OF BIRTH AGE

ASSETS, LIABILITIES AND NETWORTH

(Including those of the spouse and unmarried children below eighteen (18)
years of age living in declarant's household)
1. ASSETS
a. Real Properties*

DESCRIPTION KIND ASSESSED CURRENT FAIR ACQUISITION

VALUE MARKET VALUE
EXACT ACQUISITION COST
(e.g., residential, LOCATION
(e.g. lot, house and lot, commercial, industrial, (As found in the Tax Declaration of Real
condominium, and agricultural and mixed Property) YEAR MODE
improvements) used)

Subtotal: -
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT

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

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

TOTAL LIABILITIES: -
* Additional sheet/s may be used, if necessary. NET WORTH: Total Assets less Total Liabilities = -

Page 2 of 2
 BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(of Declarant/Declarant's Spouse/Unmarried Children Below Eighteen (18) years of Age Living in Declarant's Household)
I/We do not have any business interest or financial connection.

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS INTEREST DATE OF ACQUISITION OF

ENTERPRISE & / OR FINANCIAL INTEREST OR CONNECTION
CONNECTION

RELATIVES IN THE GOVERNMENT SERVICE

(Within the Fourth Degree of Consanguinity or Affinity, 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 below eighteen (18) years of age living in my household, and that to the best
of my knowledge, the above-enumerated are names of my relatives in the government within the fourth civil degree of consanguinity or 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 my 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) (Signature of Co-Declarant/Spouse)

Government Issued ID: Government Issued ID:

ID No: ID No.:
Date Issued: 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 2
 Revised as of January 2015
Per CSC Resolution No. 1500088
Promulgated on January 23, 2015

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of
(Sample additional sheet/s for the exclusive properties of the declarant's spouse and unmarried children
below eighteen (18) years of age living in declarant's household)

NAME: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:

ASSETS, LIABILITIES AND NETWORTH

1. ASSETS
a. Real Properties
ASSESSED CURRENT FAIR
DESCRIPTION KIND ACQUISITION
VALUE MARKET VALUE
EXACT
(e.g. lot, house and lot, (e.g., residential,
LOCATION ACQUISITION COST
commercial, industrial, (As found in the Tax Declaration of Real
condominium, and
agricultural and mixed Property) YEAR MODE
improvements)
used)

b. Personal Properties

DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT

2. LIABILITIES
NATURE NAME OF CREDITORS OUTSTANDING BALANCE

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS INTEREST DATE OF ACQUISITION OF
ENTERPRISE & / OR FINANCIAL CONNECTION INTEREST OR CONNECTION
 Page _____ of ______

Revised as of January 2015

Per CSC Resolution No. 1500088
Promulgated on January 23, 2015

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of
(Sample additional sheet/s for the declarant)

NAME: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:

ASSETS, LIABILITIES AND NETWORTH

1. ASSETS

a. Real Properties
ASSESSED CURRENT FAIR
DESCRIPTION KIND VALUE MARKET VALUE ACQUISITION
EXACT
(e.g., residential, ACQUISITION COST
(e.g. lot, house and lot, commercial, industrial, LOCATION (As found in the Tax Declaration of Real
condominium, and agricultural and mixed Property) YEAR MODE
improvements) used)

Subtotal: -
b. Personal Properties
DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT

Subtotal: -
TOTAL ASSETS (a+b): -
2. LIABILITIES
NATURE NAME OF CREDITORS OUTSTANDING BALANCE

TOTAL LIABILITIES: -

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS INTEREST DATE OF ACQUISITION OF

ENTERPRISE & / OR FINANCIAL CONNECTION INTEREST OR CONNECTION

Page _____ of ______