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, 2022
(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:

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

ADDRESS: OFFICE ADDRESS:

SPOUSE:

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

NAME DATE OF BIRTH AGE

N/A

ASSETS,
LIABILITIES
ANDNETWORTH
(Including those of the spouse and unmarried children below
eighteen (18) years of age living in declarant’s household) 1. ASSETS
a. Real Properties*
KIND EXACT CURRENT FAIR ACQUISITION ACQUISITION
DESCRIPTION ASSESSED
(e.g. residential, LOCATION MARKET COST
(e.g. lot, house VALUE VALUE
commercial,
and lot,
industrial,
condominium (As found in the Tax YEAR MODE
agricultural
and Declaration of Real
and mixed
improvements) Property)
use)

Subtotal:

b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION
COST/AMOUNT

Subtotal :

TOTAL ASSETS (a+b):

* Additional sheet/s may be used, if necessary.

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2. LIABILITIES*
OUTSTANDING
NATURE NAME OF CREDITORS
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 NATURE OF BUSINESS DATE OF ACQUISITION OF
ENTITY/BUSINESS BUSINESS ADDRESS INTEREST &/OR FINANCIAL INTEREST OR
ENTERPRISE 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 aboveenumerated 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.

EMELVYN C. VALENCIA
Officer-In-Charge
Administrative Department

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