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    This document is a sworn statement of assets, liabilities, and net worth filed by Kherlyn M. Bautista, a teacher, as required by law. It lists her personal assets including appliances worth 26,500 pesos total, and no liabilities or business interests. It also provides details about her spouse Marvin M. Bautista, who works as a pharmacy assistant, and their son Khervin Matthew. The document is signed and notarized.

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    Sample Saln

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    AN NA
    2K views3 pages
    This document is a sworn statement of assets, liabilities, and net worth filed by Kherlyn M. Bautista, a teacher, as required by law. It lists her personal assets including appliances worth 26,500 pesos total, and no liabilities or business interests. It also provides details about her spouse Marvin M. Bautista, who works as a pharmacy assistant, and their son Khervin Matthew. The document is signed and notarized.

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    This document is a sworn statement of assets, liabilities, and net worth filed by Kherlyn M. Bautista, a teacher, as required by law. It lists her personal assets including appliances worth 26,500 pesos total, and no liabilities or business interests. It also provides details about her spouse Marvin M. Bautista, who works as a pharmacy assistant, and their son Khervin Matthew. The document is signed and notarized.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    2K views3 pages

    Sample Saln

    Uploaded by

    AN NA
    This document is a sworn statement of assets, liabilities, and net worth filed by Kherlyn M. Bautista, a teacher, as required by law. It lists her personal assets including appliances worth 26,500 pesos total, and no liabilities or business interests. It also provides details about her spouse Marvin M. Bautista, who works as a pharmacy assistant, and their son Khervin Matthew. The document is signed and notarized.

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    of 3

    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 December 31, 2017
    (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: BAUTISTA KHERLYN M. POSITION: TEACHER II


    (Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEPARTMENT OF EDUCATION
    ADDRESS: 12 BANTUGAN POZORRUBIO, PANGASINAN OFFICE ADDRESS: PANGASINAN DIVISION II
    BINALONAN

    SPOUSE: BAUTISTA MARVIN M. POSITION: PHARMACY ASSISTANT


    (Family Name) (First Name) (M.I.) AGENCY/OFFICE: ST. JOSEPH DRUGSTORE
    OFFICE ADDRESS: POZORRUBIO, PANGASINAN

    UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD

    NAME DATE OF BIRTH AGE


    KHERVIN MATTHEW M. BAUTISTA OCTOBER 25, 2015 3

    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 EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION


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

    N/A N/A N/A N/A N/A N/A N/A N/A

    Subtotal:
    b. Personal Properties*

    DESCRIPTION YEAR ACQUIRED ACQUISITION


    COST/AMOUNT

    Watch 2019 500.00


    Mobile Phone 2017 10,000.00
    Necklace 2014 10,000.00
    Ring 2014 6,000.00
    Subtotal : 26, 500.00

    TOTAL ASSETS (a+b): 26, 500.00

    Page 1 of ___
    * Additional sheet/s may be used, if necessary.

    Page 2 of ___
    2. LIABILITIES*

    NATURE NAME OF CREDITORS OUTSTANDING BALANCE

    N/A N/A N/A

    TOTAL LIABILITIES: 0
    NET WORTH : Total Assets less Total Liabilities = 26, 500.00
    * Additional sheet/s may be used, if necessary.

    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 DATE OF ACQUISITION OF


    ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
    CONNECTION
    N/A N/A N/A N/A

    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
    N/A N/A N/A

    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: PAG-IBIG Government Issued ID:


    ID No.: 9122-6820-1508 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.

    MA. LUISA P. ALEGADO, PRINCIPAL III


    (Person Administering Oath)
    Page 3 of ___

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