Rosalina M.

Carloto Memorial Elementary School-Gutalac I District

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of

DECEMBER,

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
DECLARANT

Separate Filing

MENDOZA

CORAZON

R.

(Family Name)

(First Name)

(M.I.)

Not Applicable
POSITION:

Teacher-1

ADDRESS:

Barangay, Osukan, Labason

AGENCY/OFFICE:

DepEd-Zambo. Del Norte

OFFICE ADDRESS:

Rosalina M. Carloto M E/S

Zamboanga del Norte

Gutalac-I District
DECEASED

SPOUSE:
(Family Name)

(First Name)

(M.I.)

POSITION:

N/A

AGENCY/OFFICE:

N/A

OFFICE ADDRESS:

N/A
N/A

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANTS

HOUSEHOLD
NAME

DATE OF BIRTH

N/A

AGE

N/A

N/A

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

(e.g. lot, house and

lot, condominium
and improvements)

(e.g. residential,
commercial,
industrial,
agricultural and
mixed use)

LOCATION

ASSESSED

CURRENT FAIR

VALUE

MARKET VALUE

LOT

RESIDENTIAL

OSUKAN, LAB, ZN

150,000.00

HOUSE

RESIDENTIAL

OSUKAN, LAB, ZN

300,00.00

N COST
MODE

200,000.00

1987

Installment

150,000.00

400,000.00

2015

Installment

300,000.00

Subtotal:

P450,000.00

b. Personal Properties*
YEAR ACQUIRED

CIGNAL
EYEGLASS

ACQUISITIO

YEAR

(As found in the Tax Declaration of

Real Property)

DESCRIPTION

ACQUISITION

2015
2015

ACQUISITION COST/AMOUNT

6,000.00
2,500.00
Subtotal : 8,500.00
TOTAL ASSETS (a+b): 458,500.00

2. LIABILITIES*
NATURE

NAME OF CREDITORS

LENDING
LOAN

ZORAYDA LENDING INVESTORS

1ST VALLEY BANK

LOAN

RBK

OUTSTANDING BALANCE

20,000.00
35,000.00
50,000.00

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Rosalina M. Carloto Memorial Elementary School-Gutalac I District

LOAN
LOAN

RBPI
GSIS

300,000.00
45,000.00
TOTAL LIABILITIES: 450,000.00

NET WORTH : Total Assets less Total Liabilities = P8,500.00

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

BUSINESS ADDRESS

NATURE OF BUSINESS INTEREST

&/OR FINANCIAL CONNECTION

DATE OF ACQUISITION OF
INTEREST OR CONNECTION

NONE

NONE

NONE

NONE

C. 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

LOLITA S. LOPEZ

SISTER

AUDITOR

GHQ (CAMP EMILIO AQUINALDO) QUEZON CITY

HON. HERMINIO JAMANDRON

COUSIN

VICE MAYOR

DILG GUTALAC

ATTY. VIVENCIO A. SERA

BROTHER IN LAW

OIC DIRECTOR

BASILAN

FLORABEL A. SERA

SISTER IN LAW

AUDITING OFFICER

ZAMBOANGA CITY

EDGAR A. SERA

BROTHER IN LAW

MANAGER

LAND BANK (MOLAVE)

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 aboveenumerated 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 25, 2016

(Signature of Declarant)
Government Issued ID:
ID No.:
Date Issued:

(Signature of Co-Declarant/Spouse)

GSIS
956-0838340-014
09-22-2000

Government Issued ID:

ID No.:
Date Issued:

SUBSCRIBED AND SWORN to before me this 25TH day of January, 2016, affiant exhibiting
to me the above-stated government issued Identification Card.

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Rosalina M. Carloto Memorial Elementary School-Gutalac I District

_______________________________________
(Person Administering Oath)

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