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 29, 2020
(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: Department of Education
ADDRESS: OFFICE ADDRESS: Division of Palawan
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*
DESCRIPTIO KIND EXACT ASSESSED CURRENT ACQUISITION ACQUISITIO
N (e.g. residential, LOCATION VALUE FAIR MARKET N COST
commercial,
(e.g. lot, house and industrial, agricultural VALUE
lot, condominium and mixed use)
and improvements) (As found in the Tax Declaration of
Real Property)
YEAR MODE
Sub-total:
__________________
b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION
COST/AMOUNT
Sub-total:
TOTAL ASSETS (a+b):
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* Additional sheet/s may be used, if necessary.
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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.
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 BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF
ENTITY/BUSINESS INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
ENTERPRISE 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: December 29, 2020
(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)
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