Revised as of January 2015

Per CSC Resolution No. 1500088

Promulgated on January 23, 2015

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of December 31, 2019
(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: DOHINOG DG WALTER MARK G. POSITION: SST – I

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: Ampayon National High School
ADDRESS: P-3C Ampayon, Butuan City OFFICE ADDRESS: Ampayon, Butuan City
SPOUSE: DOHINOG AGNES LUZ A. POSITION: N/A
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:
OFFICE ADDRESS:

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

NAME DATE OF BIRTH AGE

AIYANA FAYNE A. DOHINOG December 23, 2010 9
AKINA JASMINE A. DOHINOG November 16, 2015 4

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 ACQUISITION

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

House Residential P-3c Ampayon, 2014 Loan Php 280,000.00

Butuan City
Subtotal: Php 280,000.00
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

Appliances 2014-2018 Php 30,000.00

Gadgets 2016-2019 Php 30,000.00
Clothing 2014-2019 Php 15,000.00
Subtotal: Php 75,000.00
TOTAL ASSET(a+b): Php 355,000.00
* Additional sheet/s may be used, if necessary.
2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING

BALANCE

Salary Loan/ Conso Loan GSIS Php 145,000.00

Salary Loan Bank/ City Savings Bank Php 180,000.00
Salary Loan HDMF/ Pag-ibig Php 20,000.00
TOTAL LIABILITIES: Php 345,000.00
NET WORTH : Total Assets less Total Liabilities = Php, 10,000.00
* Additional sheet/s may be used, if necessary.

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

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 (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 BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION

ENTITY/BUSINESS INTEREST &/OR FINANCIAL OF INTEREST OR
ENTERPRISE CONNECTION CONNECTION
NONE NONE NONE NONE

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

NONE NONE NONE NONE

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, 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
household covering previous years to include the year I first assumed office in government.

Date: ____JANUARY , 2020_________________

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

Government Issued ID: PRC ID Government Issued ID:

ID No.: 1083857 ID No.:
Date Issued: 1/25/2011 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)

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