SWORN STATEMENT OF ASSETS, LIABILITIES, AND NET WORTH

DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS

AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE
As of December 31, 200___
(Required by R.A. No.6713)
Name ______________________________________Position/Income ______________________________________
Surname First Name M.I. Office _______________________________________
Address_____________________________________ Office Address _______________________________________
______________________________________________________________________________________________
Spouse Name________________________________Position ____________________________________________
Surname First Name M.I. Office _______________________________________
Unmarried Children below 18 years of age
Name Date of Birth

____________________________________ ________________________________
____________________________________ ________________________________
____________________________________ ________________________________
____________________________________ ________________________________
____________________________________ ________________________________
____________________________________ ________________________________
____________________________________ ________________________________
____________________________________ ________________________________
A. ASSETS, LIABILITIES AND NET WORTH

ASSETS
a. Real Properties:
KIND LOCATION YEAR MODE OF ASSESSED CURRENT FAIR ACQUISITION COST
ACQUIRED ACQUISITION VALUE MARKET VALUE LAND IMPROV-
BUILDING ETC. MENTS

Total P________________
b. Personal and other Properties:
KIND YEAR ACQUIRED ACQUISITION COST

Total P________________
e. Liabilities (Loans, Mortgages, etc.)
NATURE AMOUNT

Total P _______________
NET WORTH (Total Assets (La + Lb) Less Total Liabilities (2) ______________________
NOTE: Instructions at the Back please use additional forms if necessary)
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 INSTRUCTIONS

WHO SHALL FILE

All public officials and employees, except those who serve in an honorary capacity, laborers and casual
or temporary workers, shall file in three (3) copies under oath the statements of Assets, Liabilities and Net Worth,
Disclosure of Business Interests and Finacial Connections including those of their households, and unmarried
children under eighteen (18) years of age living in their households, and Disclosure of Relatives in the Government.
Married couples who are public officials or employees may file the required statement jointly or separately.

WHEN TO FILE

1. Within thirty (30) days after assumption of office, statements of which must be
reckoned as of his first day of service.

2. On or before April 30 of every year thereafter, statements or which must be reckoned

as of the end of the preceding year; or

3. Within thirty (30) days after separation from the service, statement of which must
be reckoned as of his last day of office.

WHERE

OFFICE/EMPLOYEE OFFICE WHERE TO FILE

President, Vice President and members of Constitution Nationa Office of the Ombudsman
Commissions and offices

Senators Secretary of the Senate

Congressman Secretary General of the House of

Representatives
Justices of the Supreme Court and Court of Appeals,
Sandiganbayan Clerk of Court of the Supreme Court

Judges-Regional Trial Court, Metropolitan Circuit Trial Court Administrator

Court, City Court, Municipal and Special Court

National Executive officials such as Members of the Office of the President

Cabinet, Undersecretaries and assistant Secretaries Republic of the Philippines
including the foreign service and heads of government-
owned or controlled corporations with original characters
and their subsidiaries and state colleges and universities

Regional and local officials and employees both appointive Deputy Ombudsman in their
and elective, including other officials and employees of respective regions
government-owned or controlled corporations and their
subsidiaries and state colleges and universities

Officers of the Armed Forces from the rank of colonel or Office of the President,
Naval Captain Republic of the Philippines

Officers of the Armed Forces with ranks below these Deputy Ombudsman in their
mentioned above respective regions

All other public officials and employees not mentioned above Civil Service Commission
ty, laborers and casual
ilities and Net Worth,
ds, and unmarried
ves in the Government.
or separately.

preme Court
 B. BUSINESS INTEREST AND FINANCIAL CONNECTIONS

To have any business ether financial connections including those of your spouse and unmarried children below 18
years of age living with you in your household/Yes/No/
if yes give partiulars;

Name of Firm Nature of Business Date of Acquisition or

Name Company Address interest and/or Connection
Fincial Connection

C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

To the best of your knowledge, are related within the fourth degree of Consanguinity or of afinity or anyone working
in the government?/ / Yes / / No if yes, give particulars;

Name Position Relationship Name/Address of Office

I hereby certify to the best of my knowledge and information, that those are true statement of my assets,
liabilities, net worth, business and financial connection those of spouse and unmarried children below 18 years of
age and names of my relatives in the government as of December 31, 200__ as required by and in accordance with
Republic Act 6713.
I hereby authorized the Ombudsman or his dult 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 __________________200__ ______________________

Signature

Res. Cert. No. _______________________ T.I.N ______________________

Issued at _______________________ B: ______________________
Date Issued _______________________ ______________________
______________________

SUBSCRIBED AND SWORN TO before me this ______day of ____________200____ affiant exhibiting

his Residence Tax Identification as indicated above.
______________________
Person Administering Oath
TIONS

married children below 18

Date of Acquisition or
Connection

NMENT SERVICE

afinity or anyone working

ddress of Office

ue statement of my assets,
ldren below 18 years of
by and in accordance with

btain and secure from all

ents that may show my
of my spouse and
us years to include the year

______________

______________
______________
______________
______________

200____ affiant exhibiting

 ______________
dministering Oath
 DEFINITION OF TERMS

Real Properties- - - - - - - - - - - - - - - - - - - refer to lands (residentials, commercial, agricultural, etc.)

house and building (apartment, townhouse, etc.) together
with improvements.

Improvement- - - - - - - - - - - - - - - - - - - - - connotes valuable additions of betterment or real property

which enchances its value.

Assessed Value- - - - - - - - - - - - - - - - - - - -the appraisal on assessment of real property made by the

city, Provincial or municipal assessor.

Current Fair Market Value- - - - - - - - - - - - -means its actual value, that is, the fair value of the property
as between one who wants to purchase and, one who wants
to sell it.

Personal Properties- - - - - - - - - - - - - - - - -properties for personal use such as cash is banks, cash on
hand, jewelry, appliances, furnitures and fixtures, book, cars,
stocks, bonds and the like.

Kind- - - - - - - - - - - - - - - - - - - - - - - - - - - brief description of the property

real property farmland, residential
personal property

Mode of Acquisition- - - - - - - - - - - - - - - - -Manner by which the property is acquired,

inheritance, donation, purchase, etc.
.
Creditor- - - - - - - - - - - - - - - - - - - - - - - - - person, group of persons or company to whom one is
indebted or whom payment is due e.g. GSIS for loans,
Phil-Am for insurance, rent.

Nature of Business- - - - - - - - - - - - - - - - - refers to business interest whether as proprietor, investor,

owner, partner, shareholder, officer, managing director,
executive creditor, lawyer, legal consultants or advisers,
financial or business consultant, auditor and the like.

Relatives in the fourth degree- - - - - - - - - -consanguinity and affinity - refer to spouse, parents,
bothers and sisters and their spouse, nephews and nices
and their spouses, bilas, inso, balae, step parents, half
brothers and half sisters and their spouse.
e who wants

, book, cars,