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Sworn Statement of Assets, Liabilities and Net Worth

This document is a sworn statement of assets, liabilities, and net worth that must be filed by public officials and employees in the Philippines. It requires disclosure of real and personal assets and liabilities, as well as business interests and relatives in government. The declarant must sign to authorize investigation of the disclosures.

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Suave Revillas
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47 views

Sworn Statement of Assets, Liabilities and Net Worth

This document is a sworn statement of assets, liabilities, and net worth that must be filed by public officials and employees in the Philippines. It requires disclosure of real and personal assets and liabilities, as well as business interests and relatives in government. The declarant must sign to authorize investigation of the disclosures.

Uploaded by

Suave Revillas
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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Revised as of January 2015

Per CSC Resolution No. 1500088


Promulgated on January 23, 2015

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH


As of DECEMBER 31, 2019
(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: TEACHER


(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEP-ED CEBU PROVINCE
ADDRESS: , OFFICE ADDRESS: IPHO BLDG. SUDLON, LAHUG,
CEBU, CITY

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*

DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION


(e.g. lot, house and (e.g. residential, commercial, LOCATION VALUE MARKET VALUE COST
lot, condominium and industrial, agricultural and
(As found in the Tax Declaration of
improvements) mixed use)
Real Property)
YEAR MODE

Subtotal:
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION


COST/AMOUNT

Subtotal :

TOTAL ASSETS (a+b):


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

Page 1 of ___
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.

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 INTEREST DATE OF ACQUISITION OF


ENTERPRISE &/OR FINANCIAL CONNECTION INTEREST OR CONNECTION
NONE

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
NONE

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 ___

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