Revised as of January 2015

Per CSC Resolution No. 1500088

Promulgated on January 23, 2015

SWORNSTATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of 31 December 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: Golfo John Brian A POSITION: SN2

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DOTr-PCG CGWCEISC
OFFICE ADDRESS:
F. Ortigas St. Brgy. Addition Hills
ADDRESS: BRGY. Castaños Lejos Gen.Emilio Aguinaldo,(Bailen) Cavite
Mandaluyong City

SPOUSE: N/A N/A N/A POSITION: N/A

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

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

NAME DATE OF BIRTH AGE

N/A N/A N/A

ASSETS, LIABILITIESANDNETWORTH
(Including those of the spouse and unmarried children below eighteen (18)
years of age living in declarant’s household)
1. ASSETS
a. RealProperties*

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,
and improvements) agricultural and mixed (As found in the Tax Declaration of
Real Property)
YEAR MODE
use)

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

Subtotal: N/A
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

CLOTHING 2016 ₱ 3,000.00

CELLPHONE 2017 ₱ 16,350.00
SHOES/G-SHOCK 2018 ₱ 12,099.00
MOTOR PARTS/CELLPHONE 2019 ₱ 54,000.00
AMPLIFIER SET 2020 ₱ 17,000.00
Subtotal : ₱
102,449.00
TOTAL ASSETS (a+b): ₱
102,449.00

2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

PCGSLAI LOAN PCGSLAI ₱ 25,372.8

AFPMBAI SALARY LOAN AFPMBAI ₱ 37,888.84
ACDI ACDI ₱ 154,892.8
TOTAL LIABILITIES: ₱ 218,154.44
 NET WORTH : Total Assets less Total Liabilities = (₱115,705.44)

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

Page 1 of _2_
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

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 Omudsman 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 18years of age living with me in my household
covering previous years to include the year I first assumed office in government.

Date: 4 January 2021

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

Government Issued ID: PHIL COAST GUARD ID Government Issued ID: N/A
ID No.: CG20-E-2762 ID No.: N/A
Date Issued: 25 JUNE 2020 Date Issued: N/A

SUBSCRIBEDANDSWORN to before me this 4th of January 2021 affiant exhibiting to me the above-stated
government issued identification card.

ENS CHARLES ZEUS B MASICAP PCG

Actg DCCS for Admin and Personnel, WCEIS-1
(Person Administering Oath)
Page 3 of _2_