Sample

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, 2022
(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: NGAYON HUSBAND N POSITION: PATROLMAN

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: PHAS-ARMD HSS
ADDRESS: HAPPY ST 5 ,NAIA PASAY CITY OFFICE CAMP BGEN RAFAEL T CRAME
ADDRESS: ,QUEZON CITY

NGAYON WIFEE CO
SPOUSE: POSITION: PATROLWOMAN
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: PHAS-ARMD HSS
OFFICE CAMP BGEN RAFAEL T CRAME
ADDRESS: ,QUEZON CITY

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

NAME DATE OF BIRTH AGE

GRENDA NGAYON 10-13-2020 2 Y/O
N/A N/A N/A
N/A N/A N/A
N/A N/A N/A

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*
REMINDER: For real property covered by a contract to sell, where ownership over the property transfers
only upon full payment of the purchase price, it is declared under Personal Property. The acquisition
cost is the total amount already paid as of 31 December.
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
Real Property)
YEAR MODE
use)

If No Real Properties N/A N/A N/A N/A N/A N/A

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

HOUSE AND HAPPY ST. 5 NAIA PURCHASED
RESIDENTIAL 1,800.000.00 2,500.000.00 2016 1,300.000.00
LOT PASAY CITY
YOU CAN FIND IT IN YOUR TAX
DECLARATION AS INDICATED

LOT AGRICULTURAL SUNNY SIDE TOWN, 750,000.00 N/A 2015 DONATION 0.00
ISABELA
IF NO TAX DECLARATION, DECLARANT MAY Subtotal: Php
INDICATE “Not Applicable” (N/A) 1,300,000.00
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

CASH ON HAND VARIOUS YEARS 450,000,00

ADV HONDA MOTORCYCLE 2020 127,000.00
FURNITURE/APPLIANCE/JEWELRIES 2020-2022 100,000.00
TOYOTA INNOVA 2022 1,200,000.00
CASH ON BANK 2022 250,000.00
Subtotal : Php 2,127,000.00
All daily expenses, tuition fees , allowance/ bills etc
Php 3,427.000.00
pwede dito TOTAL ASSETS (a+b):
* Additional sheet/s may be used, if necessary.
Page 1 of _2
Sample
2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

SALARY LOAN AFPSLAI 272,000.00

SALARY LOAN PNP PROVIDENT 98,000.00
CAR LOAN BDO 1,050,000.00
PERSONAL LOAN SAND AND ROCKS CO 350,000.00
TOTAL LIABILITIES: Php 1,770,000.00
NET WORTH : Total Assets less Total Liabilities = Php 1,657,000
* Additional sheet/s may be used, if necessary.
Please Check corresponding Box Pag N/A
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(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
No relative in Gov Service/ N/A N/A N/A
Maria Changco Ngayon Aunt Teacher DEP-ED-ISABELA CITY
Vine Changco Ngayon Aunt Fire Officer BFP-ISABELA CITY

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: Date of Accomplishment ___________

Sa may mga asawa I papirma ito pag wala gawa lng ng
certification or affidavit explaining why

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

Government Issued ID: Government Issued ID:

ID No.: ID No.:
Date Issued: Date Issued:

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

JOMARICK B FELINA
Ito ang ilagay sa actual form nio as admin Police Lieutenant Colonel
OIC, ARMD__________
(Person Administering Oath)
Page 2 of _2__