Revised as of January 2015

Per CSC Resolution No. 1500088

Promulgated on January 23, 2015

SWORNSTATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of December 31, 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: BARTOLOME, KAREM M. POSITION: PCpl/ASST. PCR PNCO

AGENCY/OFFICE: PNP/SALVADOR MPS/LDN PPO
ADDRESS: PUROK 4, MALINGAO, TUBOD, LANAO DEL NORTE OFFICE ADDRESS: POBLACION., SALVADOR,
PHILIPPINES LANAO DEL NORTE

SPOUSE: BARTOLOME, JAHYRAH E. POSITION: TEACHER I

AGENCY/OFFICE: DEPED
OFFICE ADDRESS: PIGCARANGAN, TUBOD,
LANAO DEL NORTE

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

BENNDICERE E. BARTOLOME JUNE 24, 2011 9

MIA ISABELLE E. BARTOLOME DECEMBER 8, 2016 4

ASSETS,LIABILITIESANDNETWORTH
(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 FAIR ACQUISITION ACQUISITION

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

DEED
CANIOGAN, TUBOD,
LOT AGRICULTURAL 500,000 600,000 2018 OF 700,000.00
LANAO DEL NORTE
SALE

Subtotal: 700,000.00

b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

MOTORCYCLE HONDA XRM 2018 72,000.00

CELLPHONE 2019 7,000.00
PERSONAL BELONGINGS 2020 5,000.00

MOTORCYCLE ACCESSORIES 2020 2,000.00

Subtotal : 86,000.00

TOTAL ASSETS (a+b): 786,000.00

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

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2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

SALARY LOAN AFPSLAI 90,000.00

TOTAL LIABILITIES: 90,000.00

NET WORTH : Total Assets less Total Liabilities = 696,000.00

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

RELATIVESINTHEGOVERNMENTSERVICE
(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

N/A N/A N/A N/A

Iherebycertify that thesearetrueand correct statementsofmy assets,liabilities,net

worth,businessinterestsandfinancialconnections,includingthoseofmyspouseand unmarried childrenbelow
eighteen (18)yearsofage living in my household,and that to the best of my knowledge, the above-enumerated
are namesofmyrelativesinthegovernmentwithin the fourth civil degree of consanguinity or affinity.

IherebyauthorizetheOmbudsmanorhis/herdulyauthorizedrepresentativetoobtainandsecurefrom
allappropriategovernmentagencies,includingtheBureauofInternalRevenuesuchdocumentsthatmay
showmyassets,liabilities,networth,businessinterestsandfinancialconnections,toincludethoseofmy spouse
andunmarriedchildrenbelow18yearsofagelivingwithmeinmyhouseholdcoveringpreviousyears to
includetheyearIfirstassumedofficeingovernment.

Date: JANUARY 28, 2021

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

Government Issued ID: PNP ID Government Issued ID:

ID No.: 18B050229 ID No.:
Date Issued: JUNE 5, 2018 Date Issued:

SUBSCRIBEDANDSWORNtobeforemethis dayof ,affiantexhibitingto me the above-stated government issued

identification card.

(PersonAdministering Oath)

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