*With Additional Sheet: Yes No Revised as of January 2015

Per CSC Resolution No. 1500088

Promulgated on January 23, 2015

SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH

As of 31 December 2018
(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 Separate Others: _____________________

DECLARANT: JACOL JANET C. POSITION/INCOME: SST-III/₱24,224.00

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DepEd Samar Div./Baclayan NHS
ADDRESS: OFFICE ADDRESS:
Baclayan, Daram, Samar Baclayan, Daram, Samar

SPOUSE: Jacol Diosdado Jr. L. POSITION/INCOME: Team Leader/₱30,600.00

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: AFP-93rd IB, 8ID-PA
OFFICE ADDRESS: Brgy. Aguiting, Kananga, Leyte

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NAME DATE OF BIRTH AGE
Rynz Nathaniel C. Cornelio August 4, 2008 10 yrs old

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*
DESCRIPTION KIND EXACT ASSESSED CURRENT ACQUISITION
(e.g. lot, house and lot, (e.g. residential, LOCATION VALUE FAIR
condominium and commercial, MARKET
improvements) industrial,
VALUE
agricultural and
mixed use) (As found in the Tax Declaration
of YEAR MODE COST
Real Property)

House Residential P7-Mercedes, Catb. City 2012 Cash ₱110,000.00

House Residential Baclayan, Daram, Samar 2014 Cash ₱100,000.00
House
Residential Baclayan, Daram, Samar 2018 Cash ₱ 35,000.00
Improvements

*With Additional Sheet: Yes No

Subtotal: ₱245,000.00
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

Appliances & Furniture Various Years ₱50,550.00

Gadgets & Accessories Various Years ₱50,000.00
Clothing & Jewelries Various Years ₱50,000.00
Motorboat (2 units) 2014 & 2017 ₱105,000.00
Subtotal : ₱255,550.00

TOTAL ASSETS (a+b): ₱ 500,550.00

LIABILITIES*
NATURE NAME OF CREDITORS OUTSTANDING BALANCE

Salary Loan MTMAS ₱ 49,976.00

Salary Loan City Savings Bank ₱ 351,000.00
Salary Loan GSIS Conso. Loan ₱ 95,000.00

*With Additional Sheet: Yes No TOTAL LIABILITIES: ₱491,976.00

NET WORTH : Total Assets less Total Liabilities = ₱ 8,574.00

BUSINESSINTERESTSANDFINANCIALCONNECTIONS
(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 ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF

ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION
N/A N/A N/A N/A
N/A N/A N/A N/A
N/A N/A N/A N/A
N/A N/A N/A N/A

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
LAILA POLANCOS Sister EGT-I DepEd Samar/Tugas ES/Tugas, Daram, Samar
JOVELYN LACAMBRA Sister SST-I DepEd Samar/Cabiton-an NHS/Cabiton-an, Daram
JUNREY CABISO Brother Riffle man AFP-8ID/14IB/Oras, E. Samar
REX LACAMBRA Brother-in-law Riffle man AFP-25th IB-10ID/Camp Kalaw, Compostella Valley

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, networth, 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: January 18, 2019

(Signature of Declarant) (Signature of Co-Declarant/Spouse)

Government Issued ID: PRC ID Government Issued ID: Military ID

ID No.: 1061879 ID No.: A18-E-168450
Date Issued: 11/28/2016 Date Issued: 9/03/2018

*With Explanation: Yes  No

SUBSCRIBED AND SWORN to before me this day of , affiant exhibiting to me the above-stated government
issued identification card.

____________________________________
(Person Administering Oath)