SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of ________________________________
(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

DECLARANT

Not Applicable

POSITION:

:
(Family Name)

(First Name)

(M.I.)

ADDRESS:

AGENCY/OFFICE:
OFFICE ADDRESS:

SPOUSE:

POSITION:
(Family Name)

(First Name)

(M.I.)

AGENCY/OFFICE:
OFFICE ADDRESS:

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANTS 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 declarants household)
1. ASSETS
a.

Real Properties*

DESCRIPTION

KIND

(e.g. lot, house and

lot, condominium
and improvements)

(e.g. residential,
commercial, industrial,
agricultural and mixed
use)

LOCATION

ASSESSED

CURRENT FAIR

VALUE

MARKET VALUE

(As found in the Tax Declaration of

Real Property)

ACQUISITION
YEAR

ACQUISITION COST

MODE

Subtotal:

b. Personal Properties and Other Assets*

DESCRIPTION

YEAR ACQUIRED

ACQUISITION COST/AMOUNT

Subtotal :
TOTAL ASSETS (a+b):
2. LIABILITIES*
NATURE

NAME OF CREDITORS

TOTAL LIABILITIES:

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OUTSTANDING BALANCE

NET WORTH : Total Assets less Total Liabilities =

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

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

(of Declarant /Declarants spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarants Household)

I/We do not have any business interest or financial connection.

NAME OF ENTITY/BUSINESS
ENTERPRISE

BUSINESS ADDRESS

NATURE OF BUSINESS
INTEREST &/OR FINANCIAL
CONNECTION

DATE OF ACQUISITION OF
INTEREST OR 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/We hereby certify that these are my/our true and detailed assets, liabilities, net worth, amount and
sources of income, personal and family expenses, amount of income taxes paid, business interests, and financial
connections, including those of my spouse and my/our children below 18 years of age living in my household, and the
name/s of my relative/s in the Government, as of December 31, __________, as required by and in accordance with
Republic Act No. 3019 and 6713
I/We hereby authorize the Ombudsman or his duly authorized representative to obtain and secure from all
appropriate agencies, including the Bureau of Internal Revenue, such documents that may show such assets, liabilities,
net worth, business interests, and financial connections, including those of my spouse and my/our children below 18
years of age living in my household, covering previous years, and if possible, including the year I/we first assumed office
in Government.
I/We further undertake to produce all supporting documents for each of the entries herein made when required.

Date:

______________________________

(Signature of Declarant)
Government Issued ID:
ID No.:
Date Issued:

SUBSCRIBED AND SWORN to before me this

(Signature of Co-Declarant/Spouse)
Government Issued ID:
ID No.:
Date Issued:

day of ________________, 2013, affiant(s) exhibiting his/ her/their tax

identification number(s) __________________________________ and employee number (s) ______________________________________.

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_______________________________________
(Person Administering Oath)

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