Revised as of January 2015

Per CSC Resolution No. 150008

Promulgated on January 23, 20

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 separate
Joint Filing Separate Filing Not Applicable
DECLARANT: JABELO DINESSA L. POSITION: TEACHER 1
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEPED
OFFICE ADDRESS: CALBAYOG CITY, SAMAR
ADDRESS: BRGY. DANAO 1, TINAMBACAN DISTRICT
CALBAYOG CITY, SAMAR

SPOUSE: POSITION:
(Family Name ) (First Name) (M.I. AGENCY/OFFICE:
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*
CURRENT FAIR
ASSESSED
DESCRIPTION KIND MARKET ACQUISITION
VALUE VALUE
EXACT
(e.g., residential, LOCATION
(e.g. lot, house and lot, commercial, (As found in the Tax Declaration of
condominium, and industrial, Real Property) YEAR MODE
improvements) agricultural and
mixed used)

Subtotal:
b. Personal Properties*
YEAR
DESCRIPTION ACQUISITION COST/AMO
ACQUIRED
MOBILE PHONE 2018 1
Subtotal:
TOTAL ASSETS (a+b):
2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING B

TOTAL LIABILITIES:
* Additional sheet/s may be used, if necessar NET WORTH: Total Assets less Total Liabilities =

Page 2 of 2
 BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(of Declarant/Declarant's Spouse/Unmarried Children Below Eighteen (18) years of Age Living in Declarant's House
I/We do not have any business interest or financial connection.

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISI

ENTERPRISE INTEREST & / OR INTEREST O
FINANCIAL CONNECTION CONNECTIO

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 AD

MYRENE J. PERNIA AUNT MASTER TEACHER 1 DEPED

RAZLE L. JABELO SISTER TEACHER III DEPED
RECEL L. JABELO COUSIN TEACHER III DEPED

I hereby certify that these are true and correct statements of my assets, liabilities, net worth, business intere
financial connections, including those of my spouse and unmarried children below eighteen (18) years of age living in m
household, and that to the best of my knowledge, the above-enumerated are names of my relatives in the governmen
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 childr
below 18 years of age living with me in my household covering previous years to include the year I first assumed office
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 2
 Revised as of January 2015
Per CSC Resolution No. 1500088
Promulgated on January 23, 2015

ASSETS, LIABILITIES AND NET WORTH

s and employees may file the required statements jointly or separately.

TEACHER 1
DEPED
CALBAYOG CITY, SAMAR

N (18) YEARS OF AGE LIVING IN DECLARANT'S HOUSEHOLD

AGE

ABILITIES AND NETWORTH

e and unmarried children below eighteen (18)
iving in declarant's household)

ACQUISITION
COST

ACQUISITION COST/AMOUNT

18,000.00

OUTSTANDING BALANCE

Page 2 of 2
STS AND FINANCIAL CONNECTIONS
en Below Eighteen (18) years of Age Living in Declarant's Household)

DATE OF ACQUISITION OF
INTEREST OR
CONNECTION

N THE GOVERNMENT SERVICE

nguinity or Affinity, Include also Bilas, Balae and Inso)

NAME OF AGENCY/OFFICE AND ADDRESS

DEPED
DEPED
DEPED

ct statements of my assets, liabilities, net worth, business interests and

d unmarried children below eighteen (18) years of age living in my
above-enumerated are names of my relatives in the government within

er duly authorized representative to obtain and secure from all

u of Internal Revenue such documents that may show my assets,
onnections, to include those of my spouse and unmarried children
overing previous years to include the year I first assumed office in

(Signature of Co-Declarant/Spouse)

f ____________________ , affiant exhibiting to me the above-stated

(Person Administering Oath)

Page 2 of 2
 Revised as of Ja
Per CSC Resoluti
Promulgated on

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 chil
below eighteen (18) years of age living in declarant's household)

NAME: JABELO DINESSA L. POSITION: TEACHER 1

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEPED

ASSETS, LIABILITIES AND NETWORTH

1. ASSETS
a. Real Properties
ASSESSED CURRENT FAIR
DESCRIPTION KIND ACQUISITIO
VALUE MARKET VALUE
(e.g., residential,
EXACT
(e.g. lot, house and lot, commercial, industrial, LOCATION (As found in the Tax Declaration of Real
condominium, and agricultural and mixed Property) YEAR
improvements) used)

N/A

b. Personal Properties

DESCRIPTION YEAR ACQUIRED ACQUISIT

MOBILE PHONE 2018

2. LIABILITIES
NATURE NAME OF CREDITORS
N/A
 BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS INTEREST
ENTERPRISE & / OR FINANCIAL CONNECTION

N/A

Page _____ of ______

Revised as of Ja
Per CSC Resoluti
Promulgated on

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of
(Sample additional sheet/s for the declarant)

NAME: JABELO DINESSA L. POSITION: TEACHER I

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEPED

ASSETS, LIABILITIES AND NETWORTH

1. ASSETS

a. Real Properties
ASSESSED CURRENT FAIR
DESCRIPTION KIND ACQUISITIO
VALUE MARKET VALUE
EXACT
(e.g., residential,
(e.g. lot, house and lot, commercial, industrial, LOCATION (As found in the Tax Declaration of Real
condominium, and agricultural and mixed Property) YEAR
improvements) used)

N/A
 Subtotal:
b. Personal Properties
DESCRIPTION YEAR ACQUIRED ACQUISIT
MOBILE PHONE 2018

Subtotal:
TOTAL ASSETS (a+b)
2. LIABILITIES
NATURE NAME OF CREDITORS
N/A

TOTAL LIABILITIES:

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS INTEREST

ENTERPRISE & / OR FINANCIAL CONNECTION

N/A

Page _____ of ______

 as of January 2015
Resolution No. 1500088
gated on January 23, 2015

ried children

ER 1

UISITION

ACQUISITION COST
MODE

CQUISITION COST/AMOUNT

18,000.00

OUTSTANDING BALANCE
-
 DATE OF ACQUISITION OF
INTEREST OR CONNECTION

as of January 2015
Resolution No. 1500088
gated on January 23, 2015

ER I

UISITION

ACQUISITION COST
MODE

₱0.00
ubtotal: -

CQUISITION COST/AMOUNT
₱18,000.00

ubtotal: 18,000.00
TS (a+b): 18,000.00

OUTSTANDING BALANCE
-

DATE OF ACQUISITION OF
INTEREST OR CONNECTION