Sworn Statement of Assets Liabilities and Net Worth

ADVERTISEMENT
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of ________________________________
(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:
POSITION:
(Family Name)
(First Name)
(M.I.)
AGENCY/OFFICE:
ADDRESS:
OFFICE ADDRESS:
SPOUSE:
POSITION:
AGENCY/OFFICE:
(Family Name)
(First Name)
(M.I.)
OFFICE ADDRESS:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NAME
DATE OF BIRTH
AGE
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
LOCATION
ASSESSED
CURRENT FAIR
ACQUISITION
ACQUISITION COST
(e.g. lot, house and
(e.g. residential,
VALUE
MARKET VALUE
lot, condominium
commercial, industrial,
(As found in the Tax Declaration of
and improvements)
agricultural and mixed
YEAR
MODE
Real Property)
use)
Subtotal:
b. Personal Properties*
DESCRIPTION
YEAR ACQUIRED
ACQUISITION COST/AMOUNT
Subtotal :
TOTAL ASSETS (a+b):
2. LIABILITIES*
NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
TOTAL LIABILITIES:
NET WORTH : Total Assets less Total Liabilities =
* Additional sheet/s may be used, if necessary.
Page 1 of ___
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of ________________________________
(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:
POSITION:
(Family Name)
(First Name)
(M.I.)
AGENCY/OFFICE:
ADDRESS:
OFFICE ADDRESS:
SPOUSE:
POSITION:
AGENCY/OFFICE:
(Family Name)
(First Name)
(M.I.)
OFFICE ADDRESS:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NAME
DATE OF BIRTH
AGE
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
LOCATION
ASSESSED
CURRENT FAIR
ACQUISITION
ACQUISITION COST
(e.g. lot, house and
(e.g. residential,
VALUE
MARKET VALUE
lot, condominium
commercial, industrial,
(As found in the Tax Declaration of
and improvements)
agricultural and mixed
YEAR
MODE
Real Property)
use)
Subtotal:
b. Personal Properties*
DESCRIPTION
YEAR ACQUIRED
ACQUISITION COST/AMOUNT
Subtotal :
TOTAL ASSETS (a+b):
2. LIABILITIES*
NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
TOTAL LIABILITIES:
NET WORTH : Total Assets less Total Liabilities =
* Additional sheet/s may be used, if necessary.
Page 1 of ___
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
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
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:
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.
_______________________________________
(Person Administering Oath)
Page 2 of ___
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of ________________________________
(Sample additional sheet/s for the exclusive properties of the declarant’s spouse and unmarried children
below eighteen (18) years of age living in declarant’s household)
NAME:
POSITION:
(Family Name)
(First Name)
(M.I.)
AGENCY/OFFICE:
ASSETS, LIABILITIES AND NET WORTH
1. ASSETS
a.
Real Properties
DESCRIPTION
KIND
LOCATION
ASSESSED
CURRENT FAIR
ACQUISITION
ACQUISITION COST
(e.g. lot, house and
(e.g. residential,
VALUE
MARKET VALUE
lot, condominium
commercial, industrial,
(As found in the Tax Declaration of
and improvements)
agricultural and mixed
YEAR
MODE
Real Property)
use)
b. Personal Properties
DESCRIPTION
YEAR ACQUIRED
ACQUISITION COST/AMOUNT
2. LIABILITIES
NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
NAME OF ENTITY/BUSINESS
BUSINESS ADDRESS
NATURE OF BUSINESS
DATE OF ACQUISITION OF
ENTERPRISE
INTEREST &/OR FINANCIAL
INTEREST OR CONNECTION
CONNECTION
Page __ of ___
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of ________________________________
(Sample additional sheet/s for the declarant)
NAME:
POSITION:
(Family Name)
(First Name)
(M.I.)
AGENCY/OFFICE:
ASSETS, LIABILITIES AND NET WORTH
1. ASSETS
a.
Real Properties
DESCRIPTION
KIND
LOCATION
ASSESSED
CURRENT FAIR
ACQUISITION
ACQUISITION COST
(e.g. lot, house and
(e.g. residential,
VALUE
MARKET VALUE
lot, condominium
commercial, industrial,
(As found in the Tax Declaration of
and improvements)
agricultural and mixed
YEAR
MODE
Real Property)
use)
Subtotal:
b. Personal Properties
DESCRIPTION
YEAR ACQUIRED
ACQUISITION COST/AMOUNT
Subtotal :
TOTAL ASSETS (a+b):
2. LIABILITIES
NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
TOTAL LIABILITIES:
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
NAME OF ENTITY/BUSINESS
BUSINESS ADDRESS
NATURE OF BUSINESS
DATE OF ACQUISITION OF
ENTERPRISE
INTEREST &/OR FINANCIAL
INTEREST OR CONNECTION
CONNECTION
Page __ of ___

Download Sworn Statement of Assets Liabilities and Net Worth

159 times
Rate
4.5(4.5 / 5) 10 votes
ADVERTISEMENT
Page of 4