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 2015
(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: BONGALON, EVELYN C. POSITION: TEACHER III

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEPARTMENT OF EDUCATION
ADDRESS: SILAO ST. BULANAO NORTE, TABUK CITY OFFICE ADDRESS: BULANAO, TABUK CITY, KALINGA
KALINGA

SPOUSE: BONGALON CHARLIE L. POSITION: PASTOR/ MINISTER

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: ASSEMBLY OF GOD CHURCH
OFFICE ADDRESS: BULANAO NORTE, TABUK CITY
KALINGA

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANTS HOUSEHOLD
NAME DATE OF BIRTH AGE
HARRY C. BONGALON MAY 28, 1997 18
JIAN CARL C. BONGALON SEPTEMBER 28, 2007 8

ASSETS, LIABILITIES AND NETWORTH

(Including those of the spouse and unmarried children below eighteen (18)
years of age living in declarants 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)

Subtotal:
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

HOME APPLIANCES 2010-1014 35,000.00

MOTORCYLE 2011 45,000.00
VAN 2014 150,000.00
CASH ON BANK/HAND 2015 105,000.00
Subtotal : 335,000.00

TOTAL ASSETS (a+b): 335,000.00

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

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2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

CONSOLIDATED LOAN GSIS 30, 000.00

MULTI-PURPOSE LOAN PAG-IBIG 5, 000.00
LOAN MTAS 200, 000.00

TOTAL LIABILITIES: 235.000.00

NET WORTH : Total Assets less Total Liabilities = 100, 000.00
* Additional sheet/s may be used, if necessary.,

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

(of Declarant /Declarants spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarants 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

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
ROBERTO M. MAALA UNCLE ADMINISTRATOR LGU- LEMERY, BATANGAS

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: ______________________________

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

Government Issued ID: UNIFIED MULTI-PURPOSE ID Government Issued ID:

ID No.: CRN-000-1166-5186-4 ID No.:
Date Issued: JULY, 2012 Date Issued:

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

DOROTHY S. ASINGAL
Administrative Officer IV

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 (Person Administering Oath)

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