Sworn Statement of Assets and Liabilities

SWORN STATEMENT OF ASSETS, LIABILITIES, AND NETWORTH DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS, AND IDENTIFICATION OF RELATIVESIN THE GOVERNMENT SERVICE AS OF DECEMBER 31, 20 (Required by R.A. No. 6713) Position/Income Office Office Address Position Office (Surname) (First Name) (MI) Address Spouse Name (Surname) (First Name) (MI) Unmarried children below 18 years of age: Unmarried children below 18 years if age: Name 1. 2. 3. 4. 5. Date of Birth (A) ASSETS, LIABILITIES AND NETWORTH 1. ASSETS: 1a. Real Properties: Nature of property Year of (paraphernal, Acquisition conjugal or community) Current Fair Market Value Acquisition Cost Land, Building Improvements Kind Location Year Acquired Assessed Value Total 1b. Personal and Other Properties: Kinds Year Acquired Acquisition Cost Total 2. LIABILITIES (Loans, Mortgages, etc.): Nature Name of Creditors Amount Total 3. NET WORTH (Total Assets [1a + 1b] less Total Liabilities [2]) NOTE: Please use additional forms/sheets if necessary. Also, please reproduce this form back to back (B) BUSINESS INTEREST AND FINANCIAL CONNECTIONS Do you have any business interest and other financial connections including these of your spouse and unmarried children below 18 years old of living with you in your household? Yes No If yes , give particulars: Nature of business, interest and or Financial Connections Name Name of Company Address Date of Acquisition or Connection (C) IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE To the best of my knowledge, are you related To the best of my knowledge, are you related with the fourth degree of consanguinity or of affinity to anyone working in the government? Yes No If yes , give particulars: Name Position Relationship 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 13 years of age and names of my relatives in the government service as of December 31, 2003 as required in accordance with Republic Act 6713. I hereby authorized the Ombudsman or his duly authorized representative to obtain and to secure from appropriate government agencies, including the Bureau of Internal Revenue, such documents that may show my assets, liabilities, net worth, business interest and financial connection, 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 the government. Date : , 20 Signature of Spouse Signature Res. Cert. No. Issued at Date Issued TIN: Com. Cert. No. Issued at: Issued on: , 20 SUBSCRIBED AND SWORN to before me this day of Affiant exhibiting to me his/her Residence Tax Certificate as Indicated above. Person Administering Oath