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    Saln

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    The document is a sworn statement of assets, liabilities, and net worth for a teacher in Ifugao, Philippines. It includes sections for assets and liabilities, business interests and financial connections, and identification of relatives in government. The teacher declares having no spouse, children, real property, personal property, business interests, or relatives in government.

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    Saln

    Uploaded by

    Bhing Bing
    7 views3 pages
    The document is a sworn statement of assets, liabilities, and net worth for a teacher in Ifugao, Philippines. It includes sections for assets and liabilities, business interests and financial connections, and identification of relatives in government. The teacher declares having no spouse, children, real property, personal property, business interests, or relatives in government.

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    The document is a sworn statement of assets, liabilities, and net worth for a teacher in Ifugao, Philippines. It includes sections for assets and liabilities, business interests and financial connections, and identification of relatives in government. The teacher declares having no spouse, children, real property, personal property, business interests, or relatives in government.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    7 views3 pages

    Saln

    Uploaded by

    Bhing Bing
    The document is a sworn statement of assets, liabilities, and net worth for a teacher in Ifugao, Philippines. It includes sections for assets and liabilities, business interests and financial connections, and identification of relatives in government. The teacher declares having no spouse, children, real property, personal property, business interests, or relatives in government.

    Copyright:

    © All Rights Reserved
    Download as XLSX, PDF, TXT or read online from Scribd
    Download as xlsx, pdf, or txt
    of 3

    SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH

    DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS


    AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE
    As of December 31, 2020
    (Required by R.A. 6713)
    Name: Position/Income: Teacher I
    (Surname) (First Name) (M.I.) Office: Schools Division of Ifugao
    Address: Office Address: Lagawe, Ifugao
    Spouse Name: N/A Position:
    (Surname) (First Name) (M.I.) Office:

    Unmarried Children below 18 years of age


    Name Date of Birth

    A. ASSETS, LIABILITIES AND NETWORTH


    1. ASSETS
    a. Real Properties
    Acquisition Cost
    Current Fair
    Year Mode of Nature of Assessed
    Kind Location Market Land; Building,
    Acquired Acquisition Property Value Improvement
    Value etc.

    Total:
    b. Personal and other Properties
    Kind Year Acquired Acquisition Cost

    Total:
    2. LIABILITIES(Loans, Mortages, etc)
    Nature Name of Creditors Amount

    NETWORTH (total Assets(1a+1b) Less Total


    Liabilites (2)
    (Note: Please use additional; forms/sheets if
    neccesarry. Also, please repoduce this form back to
    back
    B. BUSINESS INTERESTS 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 with you in your ousehold?

    [ ] Yes [ / ] No If yes, give particulars:

    Nature of Business Interest


    Name of Firm/ Date of Acquisition or
    Name Address and/or Financial
    Company Connection
    Connection
    N/A
    N/A
    N/A
    N/A
    C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

    To the best of your knowledge, are you related with the fourth degree of consanguinity or of affinity to everyone
    working in the government?

    [ ] Yes [/ ] No If yes, give particulars:


    Name Position Relationship Name/Address of Office

    I hereby certify that these are true and correct statements of my assets, liabilities, net worth, business interest,
    and financials connections and that to the best of my knowledge, the above enumerated are the names of my
    relatives in the government within the fourth 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 Revenues such documents that may show such
    assets, liabilities, net worth, business interests, and financial connections to include the years I first assumed office
    in government.

    Date:

    (Signature of Employee)
    TIN:
    Com. Cert. No. 16882082

    Issued at: LAGAWE, IFUGAO


    Issued on: January 15, 2021
    SUBSCRIBED AND SWORN to before me on this ___ day of October 2021 affiant exhibiting her

    RESIDENCE TAX CERTIFICATE as indicated above.

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