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(Form 1) SWORN STATEMENT OF ASSETS & LIABILITIES AND NETWORTH

1994 DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS


AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE
As of December 31, 20___
(Required by R.A. No. 6713)

____________________________________________ 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

ASSETS, LIABILITIES AND NETWORTH

1. ASSETS
a. Real Properties
ACQUISITION COST
Land,
NATURE OF B
CURRENT
PROPERTY ui
YEAR MODE OF ASSESSED FAIR
KIND LOCATION (paraphernal, ld
ACQUIRED ACQUISITION VALUE MARKET Improvements
conjugal, or in
VALUE
community) g,
et
c.

Total P _______________
b. Personal and Other Properties
KIND/S YEAR ACQUIRED ACQUISITION COST

Total P ________________

2. LIABILITIES (Loans, mortgages, etc.)


NATURE NAME OF CREDITORS AMOUNT
Total P ________________

NETWORTH [Total Assets (1a + 1b) less Total Liabilities (2)] Total P ___________________
Note; Please use additional forms/sheets if necessary.

B. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

Do you have any business interest and other 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 particulars:

NAME NAME OF ADDRESS NATURE OF DATE OF


FIRM/COMPANY BUSINESS INTEREST ACQUISITION
&/OR FINANCIAL
CONNECTIONS
OR
CONNECTION

IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

To the best of your knowledge, are you related within the fourth degree of consanguinity or affinity to
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 these are true statements of my assets,
liabilities, networth, business interest and financial connections including those of my spouse and unmarried
children below 18 years of age and names of relatives in the governments as of December 31, 19__, as required
by and in accordance with Republic Act 6713.

I hereby authorize the Ombudsman or his authorized representatives to obtain and secure from all
appropriate government agencies, including the Bureau of Internal Revenue, such documents that may show my
assets, liabilities, networth, 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 the government.

Date ____________________, 20 ___

_______________________________ __________________________________
Signature of Spouse Signature

TIN ___________________________ TIN ______________________________

Com. Cert. No. __________________ Com. Cert. No. _____________________


Issued at: _______________________ Issued at: __________________________
Issued on: _______________________ Issued on: __________________________