_ Bag_ol-ola Neier copy Republic of the Philippines Department of Finance BUREAU OF CUSTOMS 109 Manila MEMORANDUM FOR i All District Collectors All Heads of Offices All BOC Personnel FROM f cuore, CESE, MPA, Deputy Commissioner, Internal Administration Group SUBJECT : Processing of Retirement Benefits DATE d January 15, 2018 1. Reference: Verbal Instruction of the Commissioner 2, During the January 15, 2018 joint Flag Raising ceremony at the POM Grounds, the Commissioner reiterated that retirement benefits shall be given to BOC employees at the actual date of their retirement. 3. In this connection and in view of the fact that recording of our leave credits, filing of SALN and issuing clearance requirements are decentralized, you are hereby directed to ensure that prospective retirees from your office are provided sufficient time (at least 6 months prior retirement date) and assistance in processing the required documents and forms, as herein attached. 4. For widest dissemination and compliance.MP ee copy REPUBLIC OF THE PHILIPPINES Annex A DEPARTMENT OF FINANCE BUREAU OF CUSTOMS MANILA 1093 | Letter of Intent to Retire Date) Dear Sir: Greetings! | have the honor to inform your good office to my retirement from the service effective Jam yery grateful for the personal and professional growth that ! have gained in the Bureau for the past ‘years and looking forward.to an enjoyable and well deserved retirement. Thank you and more power! Very truly yours, (Name of Retiree & Signature)Ub vi-vie FD REPUBLIC OF THE PHILIPPINES DEPARTMENT OF FINANCE BUREAU OF CUSTOMS MANILA 1095 Annex 8.6.1 CLEARANCE OF NO OUTSTANDING ACCOUNTABILITIES To Whom It May Concern: Pursuant to the provisions of the Government Auditing Rules and Regulations, and in the Processing/ Payment of Retirement Benefits of BOC Employees, it is hereby certified that clearance as herein indicated has been granted to Mr./ Ms. Je ___,former ‘i ia a _, for the purpose of his/her Optional/Compulsory Retirement effective _ Chief, Revenue Accounting Division Financial Service MARILOU A. CABIGON Acting Chief Accountant, Accounting Division Financial Management Office ~~ Chief, Budget Division Financial Management OfficeDOG Ol - 02 Pa wuscacmemiame veka copy DEPARTMENT OF FINANCE BUREAU OF CUSTOMS MANILA 1099 (Application for Clearance of No Outstanding Obligations) (Date) The Manager Philippine National Bank Dear Sir/Madam: May | respectfully request your good office to issue in my favor a Certificate of Clearance of No Outstanding Obligations in view of my optional/compulsory from the service effective Your kind consideration on this matter shall be greatly appreciated. Very truly yours, (Name) (Position) (Port /Office)BUREAU OF CUSTOMS MANILA 1099 CLEARANCE OF NO OUTSTANDING PROPERTY ACCOUNTABILITY To Whom It May Concern: This is to certify: that, Mr./Ms,__ former has no outstanding property accountability as of even date. This certification is being issued upon the request of Mr./Ms, in view of his/her Compulsory/Optional from the customs service effective Bante ~ Chief, General Services Division Administration Office, IAG Management Information System and Technology DEPARTMENT OF FINANCE SPER eine"pele op ot ran | REIDEPARTMIENT OF FINANCE M Ye R COPY BUREAU OF CUSTOMS MANILA 1099 (Application for Clearance of No Unliquidated Cash Advance) (Date) The Chief Accountant Accounting Division Financial Management Office Dear Sir May | respectfully request your good office to issue in my favor a Certificate of Clearance of No Unliquidated Cash Advance in view of my compulsory/optional effective Your Kind consideration on this matter shall be greatly appreciated. Very truly yours, (Name and Piantilla Position)Bole al-Ol2 pF MAST REPUBLIC OF THE PHILIPPINES FEPECOPY DEPARTMENT OF FINANCE BUREAU OF CUSTOMS) = “"™"* MANILA 1099 DECLARATION OF PENDENCY/NON-PENDENCY OF CASE L Filipino, of legal age, with permanent address at SES and holder ofthe position: at the sworn in accordance with law, hereby depose and state that 1. lam applying for my COMPULSORY /OPTIONAL from the government service effective : 2.thave: 2.1 no pending case 22a pending case + administrative disciplinary case criminal case 3. The NATURE/SPECIFIC OFFENSE CHARGED in the pending criminal administrative disciplinary case is 4. The Venue of the investigation trial 5. 0n appeal: YES NO. Oo 6. The appeal is pending before: 7.1 am executing this Declaration of Pendency/Non-Pendency of Case to attest to the truth af foregoing facts and to enable me to process and secure the release of my retirement bemefits. 8. By executing this Declaration of Pendency/Non-Pendency of Case, hereby authorize the GSIS to verify the status of any case(s) fled against me in any forum, 9. Furthur, lam executing this Declaration of Pendency/Non-Pendency of Case under pain of criminal and/or administrative liability under existing laws. (Signature aver printed name) ‘SUBRIBED AND SWORN to before me this__dayof___affiant exhibiting tome his/her (Person Administering Oath) ‘A pending case shall refer to bath criminal and administrative dgcipinary case, An administrative dseplinary case is ‘considered wien the disciplining authority has issued a formal charge ora ntice tothe respondent. while a erimina case shall be ‘considered pending rom the time an Information or Complaint fled in Court.uta et te REPUBLIC OF THE PHILIPPINES MAS aR COPY DEPARTMENT OF FINANCE BUREAU OF CUSTOMS MANILA 1099 Request for Legal Clearance The Director Ill Legal Service Sir Respectfully request your good office to issue a clearance in my favor in view of my compulsory/optional effective Your kind consideration on this matter shall be greatly appreciated. Very truly yours, (Name of Employes) (Position) (Office)Dus oles 4 REPUBLIC OF THE PHILIPPINES DEPARTMENT OF FINANCE BUREAU OF CUSTOMS MANILA 1099 Republic of the Philippines) City of Manila Iss of AFFIDAVIT OF UNDERTAKING boo of legal age, married /single and resident under oath, depose and state the following: 4 “ That |am a ieee who will be ‘Praia Postion) (oice/Por) Retiring (compylsory/optional) from the service on zl That | am applying for my terminal leave benefit after rendering service for years; That there is no pending criminal investigation and prosecution against me; That whatsoever excess will be found in my Terminal Leave Benefit paid by the Bureau will be returned by the undersigned; That the undersigned is authorizing the Bureau to deduct all his/her obligations/accountabilities; That | am executing this affidavit to attest to the truthfulness of the foregoing and for purposes as one of the requirement in the processing on my Terminal Leave Benefit; FURTHER AFFIANT SAYETH NAUGHT, to (Name and Signature of Affiant) SUBSCRIBED AND SWORN to before me this affiant exhibiting me his/her CTC No. issued at ons darol-012 tio t ae we peraRt mee OF inane oe BUREAU OF CUSTOMS MANILA 1099 PORT CLEARANCE To Whom It May Concern: Pursuant to the provision of the Government Auditing Rules and Regulation, and in the Processing/ Payment of Separation Benefits of BOC Employees, it is hereby certified that clearance as herein indicated has been gtanted to Mr/Ms for the purpose of his/her (Name) (Position/Port) Compulsory/Optional retirement effective ‘Division Chief/ Subport Collector Disbursing Officer Supply Officer Legal Officer (if any) District CollectorMASTE COPY ole Old ex BD CSC Form No. 6 APPLICATION FOR LEAVE Revised 1984 Fee eae eee TOF FICE/AGENCY Ta Wie Maal) Bureau of Customs TDATEOFFIEING POSITION S'SALARY (Monthy DETAILS OF APPLICATION 6.(a) TYPE OF LEAVE Vacation ‘To seek employment Others (Specify) TERMINAL LEAVE Sick Maternity Others (Specify) TERMINAL LEAVE. 6. (e) NUMBER OF WORKING DAYS APPLIED FOR, INCLUSIVE DATE: (0) WHERE LEAVE WILL BE SENT: (1) IN CASE OF VACATION LEAVE Within the Philippines (2) IN CASE OF SICK LEAVE In Hospital (Specify) Out Patient (Specity) COMMUTATION Requested Not Requested (Signature) 7. @) CERTIFICATION OF LEAVE CREDITS as of Vacation Sick Total Days Days Days 7.(@) APPROVED FOR: Day/s with pay Day/s without pay Others 7.(b) RECOMMENDATION Approval Disapproval due to (Director HUDistriet Collector) 7.(@) DISAPPROVED DUE 10: Deputy Commissioner Internal Administration Group. STRUCTION |. Application for vacation of sick Teave of absence for one (1) fll day or more shall be miade on this form and to be accomplished at leas in duplicate Application fo vacation leave af shsence shal be filed in advance Application for sick leave filed in advance, or exceeding ive (5) days shall be accompanied by a medial ceatiieate. In case medical 1 whenever possible, five (5) das belore going on such leave. consultation was not availed of, an affidavit should be executed bythe applicant 4. An employee who fs absent without approved leave shall not be ented 1o receive his salary comesponiing tothe period of his unauthorized lave of absence 5. An application for leave of absence for thy (30) days ot more shall be accompanied by a clearance from money and property sccountabiltpots-o1 aa. MASYPRCOPY [Srigie erica Roca iazea by FaMO|rcizalng he FaTibe © Ga OT eae 7 |pia'pay ancorcersteoton tthe ele da etc on ware of obwence w/o “INET —Teeracnve on (eer fer lee [gouralson [Dale RECEVED: TE ae] ne peraeancl "REQUIREMENTS NEEDED REMARKS, Tare Saran fae orp SS [ 7 _[Griginal cunning balance of jaave credits [Campulation o! ALC) aoe t 2 ese aiib isms Sonoma a ee o eaieearnens | | t [Coniiea cop oigion NOSAINOS F [Soging Comics olan Reyrneni Sor [Gain wea Giearones. [Geainoi Pe Cawronce 12 [Onsine Group Crsrones 13 | aia er ceriiac copy of Ombudiman Gaerance 15 [ognal OP cecronce i Pendent epraini) 16 Jeoonce one uniuidolea Cosh advance: 1 [Geeronce of No Guslanding Accouniabuey 4 17 [Giesonee of Ouilonding Obtains: [ae [= tna tank Clesronce | —_PNA Clearance. { F_|Giginal or ceria copy oeer tintent reir) wierafveagraion | 21 [Oiainal or ceriies copy ol aceeoiance at rewementreianotion | [elie racuet for payment Vomit aove oa wih iiacl AGAIN Provider Fund (2 ESA : 1 a eee sal iain’ ex skUN oso es doy a sanice|eampusarvVoplionceignain w= es) lay on sevice ecora deceased ila SALN nl Bi |Ossinalofovi of unsstating Farm Annex 5 plGized) [otoina cony of G9s application for remament under RA S60, A161 PO TV80 ond lan az71/sepcrauoram ne sizine uy, Savor emote BD estomant Gratay Computation lorRa 16\6rleemert mode) [731 ferpioymers Ceniicaie 1 [root of Saching gol hein ond Guarani 2 [atari ot Guorcensnp Wm 3 |atiaari ot Suvivng Spo 4 [ean Canticate of ex sunivig hale [SO Cerifock 3 [boain Corifeole 0 Ceteat — 7 [besgretion cl ext of hin Imoiage Ceriiota sO Coriiod) waiver af Riis i eniaien 16 yeos oi ord above lacgurete chaser W ony) neluel edopled esr ot sr maoge To [Osainarrenceed Dota nest T]_ [afison oT AL compulion hela llening lobe a eri Comput hake Vvois oniicoien Cord ofA the climoniapreteabiyinved uy he goverment [aie Grae Toren wOATGaanyaiCea id pOWBy The BOC, L 13 Joones'oy al enactsMASE COPY INFORMATION ON VARIOUS MODES OF RETIREMENT. Retirement benefits of goverement employees are covered'by RA 8291, otherwise known as the Govemment Service Insurance Act of 1997. RA 8291 provides forthe folowing benefits: : + The Jump sum equivatent to 60 months of the basic monthly pension (BMP), i payabio t the time of retirement plus an old-age pension benefit equal to te. besic monthly pension payable for ite, starting upon the expiration of the five: years covered by the Jump sum; oF fl + Acash payment equivaient to 18 months of hisfnor Basic monthly pension pds ‘monthly pension for if payable immediately Conditions for entitlement to retirement benefts under RA 8291; + He/She has rendered at least 15 years of service + He/She is at east 60 yoars of age at the time of reliement + _ He/She is nol receiving @ monthly pension baneft for permanent total disebilty . However, retiring employees who entered the service Before June 1, 1977 and who have hot received any separation or retirement benefit, have the option to retive under RA 8291 as ‘above oreny of the two other retirement laws, as follows: at ‘+ RA No. 1616~ for those who have rendered at least twenly (20) years of service. This isa lump sum payment of benefits basod on besic monthly sslery and years ‘of service in the government without any pension and payable by the Bureau, * through release from DBM Pension and Gretuly Fund. + RANb. 660 - for those who pass the “Magic 67” ertera, that i, when the length of service and age at retirement are summed up, the total is atleast "87" This {involves payment of lump sum and monihly annuity by GSIS : (Aciitional information on the various modes of retirement are at the back portion of the GSIS Form, Application for Retirement and Other Social Benefits) t INSTRUCTIONS TOTHE RETIRING EMPLOYEE H Determine the mode of retirement you are qualified and wish to aval of (you may seek the assistance of your local GSIS/HRMD/Administrative Division) in coming-up with estimated benifits fo help you in decision-making Read CMO 3.2013 dated July 16, 2013, entitled, Rulos, Regulations and Procedures in the Processing/Payment of Retirement Benefits of BOC Employees Accomplish all documents hereto attached. ‘Submit the completed documentary requirements to HRMD, if your current assignment Is an officefdivision under the Office of the Commissioner, or to the Administrative Division of your District, if your current assignment is in a port or subport, Pursuant fo CMO 3-2013, implementing RA 10164, otherwise known as an Act Requiring All Concemed Government Agencies to Ensure the Early Release of Retirement Pay, Pensions, Gratutties and Other Benefits of Retiring Government Employees, Civ! Service Commission (CSC) Resolution No, 1300237 and Dopartment of Budget and Management (DBM) Circular No. 2013, the complete requirements must be submitted on or before 120 days prior to the effectivity of your retirement in order for you fo avail of the early and expeditious release of your retiroment benofts. Should you fal to comply with this preseribed period, please be hotifed thatthe release of your benefils shall be moved corresponding fo the number of days of delay of submission of complete requirements Your submitted documents shall be processed by HRMD/Administrative Division, will be endorsed fo the Office of the Deputy Commissioner, Internal Administration Group for fijal approval and endorsement fo GSIS/DBM, as applicable,Ol 01-012 tq MASTHRWCOPY ANNEXE DOCUMENTS TO BE PROVIDED TO THE RETIRING EMPLOYEE BY HRMD FOR SUBMISSION TO HMDIADMINISTRATIVE DIVISION, AS THE CASE MAYBE, 120 DAYS PRIOR TO EFFECTIVITY OF RETIREMENT Tnetritone Date of Submission] to | HRMDIAdminitatiy eDhision consemmed ‘pplaation for Reivement and iar Socal insurance Gene (GSIS Form attaches), eeu 2012.06.27 leas Toad insucions carey Pease ‘accomplish in 3 original cops, & indicts tho mods of relremant you wish o aval ‘pplcalion for Terminal Ceave Benefits (rarm attached) ‘lagew accomplish nF cignal copies Ext Statement of Assets, LSE {Notworh (SALN) as of he dato of retirement Please submit 7 aiginal and 2 copies (Original or eariied was copy of ‘audted eave cards, # you have ‘eve been assigned ina porVsubpor of entry Plaase proceed a the Adminitrative Dhvsion of he Collection Disiit where you have been assigned during your service n ‘the Bureau and request that offs ta auatt and sign your leave card forthe duration of ‘your assignmentin that port. The leave ‘ard ofall ESS personnel shall also be ‘uct by the Personnal Secton, ESS. ‘Afidavit af underoking hat hehe has ne pending rina Investigation or prosecution and thal whatsoaver excess willbe found in he terminal leave Denes ‘and retirement gratty paid by OC shal be returned wth auihorty to deduct a nismher financial obligations by BO (Form stiches) ccompish and submit in’ original (iearances) GroupiPort Clearanoa (Form attached) laase have Wis Tar signed by he ‘concemed chiefs as indeated in your GrouprDistiet. Please submit 1 original ‘and 3 copies | Ciesrance of Fendencyilon- | Pendoney of Case frm OMS (For attached) Please accorapish ie form and Rave received at OMB Cental Ofico/Regional Office and totow-up ts release, Please submit eriginal and 3 copies ‘Clearance of PendeneyiNion- Bendency of Case ftom BOC-Legal Service (Form attached) Please sccompish ie form and have! feceived at tne Legal Service, Ocomand {olowup is ‘eloase. Please eubmi 1 ‘ginal end 3 copies ‘ioaranca of Pendenayinion- Please accomplish tho foam and have Pendancy of Case fom Ci recaived at C&C Fiold OfficolCental Office Service Commission (Form ‘and fallow-up its release. Please submit t | attaches} ‘riginal and 3 copies ‘earance of Pandeneyinion= Pandoncy of Case from Office of the Presdon for Precigentiat, appointees only (Form attached) Please accompish the Yorn and have acaived a the Offi ofthe Pracisont followup ie releaze, Pleasa eubmt 4 ‘orginal and Sepia Cloaranco of No Uniquidsted Cosh Ravancels from Aceounting Division, only iretiee's last assignment is not under Ocom (Form atacres) Please sccompich tis orm and haved signed by the Accounting Division and submit rignal and 3 copies ‘Clearance of No OWSTaRSIng Property Accountabiies(Foi taened iaaze accanipi tia form and have signed by MISTG and GSO and submit 1 ‘nginal and 2 copies ‘Clearance of Wo Outstanding Obigatons wih PNB, LBP. Provident Fund & Customs Mull Purpose Cooperative (Forms tached) Ploase accomplish each orn and have facaived by eoncemed offices, folow-un thelr releases an submit 1 original and 3 copies of each Cioarance of Ne Outsiancing AAcsountabities, only reree has pertermed the datos ofan ‘Acsountable Officer (Form tached) lease sccomplih iis rn and have is signed by eaneomed offecs and submit 1 Gigial and'3 copies,Dols-o1-012 Pig guess (5) APPLICATION FOR RETIREMENT ©) SEPARATION/ LIFE INSURANCE BENEFITS Gsis Form No. 0620177 [ INSTRUCTIONS: Ensure that the application form is properly filed out and submit Guly accompilched application farm to the ] nearest G55 fice, WARNING: rect oF indirect commission of fraud, collusion, falsification, mlsrepreseatation of fects, or any other kind of anomaly in the accomplishment of this form, or in obtaining any benefit under this application shall be subject to | saminisvative civil ang/or criminal action, Dates "hereby apply fora retirement/separation/life insurance benefit with the GSIS and declare to the best of my knowledge the following: | TestWome Fist Name _ [aera ~~] Gis Basness Partner [OPIN [ Complete wating Address Date oF Binh imma Peeetiak —Yoender CI Femete ae ve iS : ae 2 r oe a ar jee ae er as Be een Givi status CY atried EY Single ‘married, Hame of Spc ‘st Neme, Middle Name) | : Di serarted Cl vidowrwisower | cree ; Tremere Peis aca oeeeroeees Tineeo El anieie “ave the honee to apy for eee [LE “tetrcmentbenefts under the revement de avkad below elective = ese my cosen pon Paseo Tem an Condon of exc alent mode on be RETIREMENT OPTIONS [TL Batcw age 60, wenihivanniitypayabieannoaly for years [Z] Aved 60 to below 63, 3-year lump sum, 2 yeas balance payable on the 63" Birthday monthly annuity after the 5-year guaranteed period 1 g0s 63 and above, 5-year mp sum, monthly erly ar the 5-year uaranteed geriod airy aratare 9ages) SIGNATURE [Crome immediate Monthly Pension 60 months x Basic Monthly Pension (StaP) and BMP after years A 8291 | [EJ Option 1: GO months x BaP and BMP alter 5 years —— EG ontion 2: 18 months x MP and BMP to start on date of etrement Ea os |(C Refund of Retirement Premiums etirementuratuity to be paid “i Ce idly lst Emplover) "APPLICATION | 17 you opt to rete under a retirement seheme with an immediate monthly pension, you may setle your FOR CLASP | outstancing loon obligation on installment basis under the Choice of Loon Amortization Schedule for Pensioners | (ASP) program, The remaining bolonce of your outstanding cbgation sol be restructured 0s 000 with an Interest rate of 20% per annum compounded annvelly (pace). Please indicate your choices below: ‘As payment for my outstanding obligation, please deduct from the proceeds of my retirement benefit the mount equivalent to seaatine. 100%, since | am nat avaing the CLASP 7%, remaining balance of 258 shal be paid through CLASP. ‘50%, remaining balance of 30% shal be pad through CLASP 25%, remaining balance of 75% shall be pad through CLASE roferred repayment tom forthe remaining balance: year Dears 3 years * conien thet | bove rod and July wncerstoed the PENSIONER RESTRUCTURED LOAN (PR) Terms and Conditions ord Lundertoe to comply with them, Pursuant r Repu Act (RA No. 9510, otherwise known asthe “raat Information Stem 4c ond ts nplemening Rules and Regulations 1) (herby acknowledge and content: 3 the regular subesion enc ‘flonre of my basic cree daa and updotes thereon tothe Cre formation Corporation (IC and 3) the sharing of my ‘si cet dato with lenders authaies by the CC. and eet reporting agencies ara outsource enti cy occredted by | te ic subiec tohe provisions of RA. No 9510, 5 Rand other relevant ows and regulation. Issue No. 01, Rev. No. 01 (16 Aug 2017), FM-GSIS-OPS-PCC-01PUG ROl (2 Pw [1D seeanarion wenéttr wa s2ettectve inm/ae/yeen [stenaudne | Cbetow 0 yeas wih es tan 15 years servic ah Bena pablo ac BY oa | Di setow 60 years old with mare than 25 years in sévice (Cash Benefit payable upon separation ‘24 monthly pension upon reaching bge 6) old and above with ess than 15 years inservice (Cash Benet payableimmediately) | 10 bri my Ocatation of Pendency/ivon:Pendency of ce, duly subsalbed and'sworn to | Pendeney/Non- | before 2 Notary Public ar Administering Officer of miy agency-employer as 4 condlon fr the release of | Pendency of Case | my retirement benefit and in céimpiance with Secticn Il of CSC Resolution No. 1302242 dated 1 October L 2013 iFEINSURANCEBENERIT Ge [vo rte maar” Ey campabary LT Oona _ NAME OF CLAIMANT IF MEMBER IS DECEASED. [last ame First Neme ‘Complete Malling Address Date of Birth imm/dd/yry) Relation to| | Contact tte JCeiphone No, Tipe af bene sped to DD Maturity Benefits TE Cap Surender vaue/Terminaion Value ew of my tetrementeteve | reenation/sparation rm hc governannconiee on | s+ Ejeaeenee (Di oesth tenets: Dave of eat eo ae | accidental Death Benefit (ADB) (applicable for ‘CM(LEP|/Optional policies) {tis understood that the entire outstanding balance of my policy as well as the arrearages and balances of my other loans and accountabilities with the GSIS which are due and demandable shall be | | deducted from the said benefit pursuant to Articles 1231 and 1278 of the Civil Code ofthe Philippines, A 8291 and the existing policies of the GSIS. Printed Name and Signature of Witnesses to Thumb mark: 1 Signature of Applicant aver Printed Name "Thumb marke (fable to affix signature) lair proceeds shall electronically credited to your eCara/UtMio account ond moy be withdrawn from your nearest bank oF ATM. if you have no eCard/UMID, the proceeds wil be poid through check. "TO BE FILED OUT BY HEAD OF AGENCY OR Hs AUTHORIZED ENDORSING OFFICER [TF endorsament | Respectfuliy forwarded to G3is this application for retiremanU separa nproval, It's hereby certified that the applicant: (Pace a check v} mark onthe pertinent box only) [7 has no pending adminstrative/eriminal case, } a | 2 Ei} nas pending administrative/eriminal case at. 3. Ey has a decided administrative case with (Please attach certified copy of Decision) 4, Ey has a decides eriminal case witn (Please attach certified copy of Decision) 5: EF sapniving for Retune of Premiums under RA 3616 and the application for gratulty benefit has been approved | by this Office Signature over printed nome ofthe Head of Agency Date signed: | orhis Authorized Endorsing Officer tice name Office address Application Received 8y: Date Receivers ‘TMS Reference No:Belk-ol O12. ee ie Promulgated on Jay 29,2085 SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of a M Required by RA 6715) Mote: Husband and wifewho are bath pubic ofcals and employees may fie the required statement ently or separately, D voit Fiting O Separate Filing Q. Not Applicable Wily _AgENc¥/orrice; OFFICE ADDRESS: DECLARANT: Family ame ADDRESS: — srouse: POSITION: i Tanily Namey Trt Rane) Til) AGENC¥/orFicE: OFFICE ADDRESS: eee -IGHTEBN (18] YEARS OF AGE LIVING IN DI Hot LD UNMARRIED CHILDREN Kame, DATE OF BIRTH AGE ASSETS, LIABILITIES AND NETWORTH Ancluding those of the spouse and unmarried children below eighteen (18) years of age living in declarant’s household) 1. ASSETS Real Properties* DESCRIPTION] KIND EXACT assessep | curRENT Far) acquistrion | acquisition eae rocatton | _vawwe _| maRKer vawue| ‘cosr a | ebuedgittsieowsinet” | yma | MODE l i = i ‘Subtotal: b, Personal Properties* DESCRIPTION ‘YEAR ACQUIRED ‘ACQUISITION ‘cost/AMOUNT (3 ee f ‘Subtotal ‘TOTAL ASSETS (a+b): Additional sheet/s may be used, if necessary. Page J of __. LIABILITIES* ; GL utter copy oe ‘ams oF corona] ‘Whrstanouie aacanca] ‘TOTAL LIABILITIES: NET WORTH : Total Assets less Total Liabilitie * Additional sheet/s may be used, if necessary BUSINESS INTERESTS AND FIN: CONNECTION: (of Declorant /Dectarant’sspouse/ Unmamied Children Below Eighteen (18) years of Age Ling in Declarant Household) OY We do not have any business interest or finazcial corinection | waster erv/aoswass | usiveas aponess | wavuna or wamese | pavwor acquiow oF tntearoe vtec cron mania, | refunion Sea Oy " conmion RB /BRUMENT'S (0¥ahin the Kourh Degree of Consanguinity or Aft. neue aso fas, Balas and las) OY We do not know of any relative/-s in the government service) [wang FiO ~ posit i OF AGENGY/ OFFICE AND | hereby certily 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. | 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 houschold covering previous years to include the year I first assumed office in government, ales eee ee ee eee eee Signature of Destarands (Signature of Co Declarant] Spouse) (Government issued 1: ‘Government Issued 1D: Do, Dro. Dae ised: 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) Page 2 of __a es . Republic othe Philippines we eae Office of the Ombudsman ‘Agha oe Digs Gatos Cy To 2. Daly AccamplshesAppstion Ferm and10 4 Ceri eo fre acre etvemest/ResgatonGuposes 2. Catia cory t sere eco and Beth Coens or seme purposes aA eee hs /ARANCE ost OF CLEARANCE PIER eee Tea SAIN [ST Brotessing Fee Bldd.o0 ap Stuhs Beoceselng Red BE600: cy 0] : Toa Petre rectvonte) Ic re Fietenion esecty one) | 97 I sy reich [Eoeats clam [Phseconeonravars esvoratition eave Aapteation Ges SEE Loo sonication Boer Fesee esrensiame vty tm roneton Jowensrge JResuireent by 18 3, CES, Otis Sf the WeTaeTR A ae ocr : b aa SaSNE HE RBGOT CECE ar Firearm tenses REE ACER Reacher Mon re parte t:h8 “Drew othe Ombudsman Clarence Fe Lesereisa cen ions ramen sae i LEASE = LEAVE SUARRF ERI BARU Stas? CO rcsap cr ome oice ae TO cease ma ¢ 0 Cresta aPUIEA ARNT a + : ay Shite : " ena 24. Name of Agenoy/oitca ty ‘euclontl | be [atta Waksoioal él atonalDelb 0! -O12 M AS im at For etuemen urpoiesan apleain sal be oessed oot eae than se) months belere the dicot evament