SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS AND IDENTIFICATION OF RELATIVES

IN THE GOVERNMENT SERVICE As of December 31, 2010 (Required by R.A. 6713)

SURNAME ADDRESS : SPOUSE'S NAME :

FIRST NAME

MIDDLE NAME

POSITION/INCOME : OFFICE : OFFICE ADDRESS : POSITION :

SURNAME

FIRST NAME

MIDDLE NAME

UNMARRIED CHILDREN BELOW 18 YEARS OF AGE : NAME DATE OF BIRTH

A. ASSETS, LIABILITIES AND NETWORTH 1. ASSETS A. Real Properties

NA T URE OF Y EA R M ODE OF A CQUI SI T I ON PROPERT Y A SSESSED V A L UE, P CURRENT FA I R M A RK ET V A L UE, P A CQUI SI T I ON COST , P L A ND, BUI L DI NG, ET C.

KIND

LOCATION

A CQUI RED

(par apher nal, conj ugal or community)

Total P B. Personal and Other Properties KIND/S YEAR ACQUIRED ACQUISITION COST, P

Total P 2. LIABILITIES (Loans, Mortgages, etc) NATURE NAME OF CREDITORS AMOUNT, P

Total P NETWORTH (Total Assets 1A & 1B Less Liabilities (2)) P

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 :

NA T URE OF BUSI NESS,

NAME

NAME OF FIRM/ COMPANY

ADDRESS

I NT EREST A ND/OR FI NA NCI A L CONNECT I ON

DATE OF ACQUISITION/ CONNECTION

C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE To the best of your knowledge, are you related within the fourth degree of consanguinity or of 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 interests and financial connections including those of my spouse and unmarried children below 18 years of age and names of my relatives in the government as of December 31, 2009, 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 documentsthat may show my assets, liabilities, networth, business interest and financial connection, to include those of my spouse and unmarried children below 18 years of age living with me in household covering previous years to include the year I first assumed office in the government.

DATE:

Signature of Spouse TIN: Comm. Cert. No. : Issued at : Issued on : TIN: Comm. Cert. No. : Issued at : Issued on :

Signature

SUBSCRIBED AND SWORN TO before me this _____ day of _________, 20_____ affiant exhibiting his/her Community Tax Certificate as indicated above.

(Person Administering Oath)

ATEMENT OF ASSETS, LIABILITIES AND NETWORTH F BUSINESS INTERESTS AND FINANCIAL CONNECTIONS CATION OF RELATIVES IN THE GOVERNMENT SERVICE As of December 31, 2010 (Required by R.A. 6713)

DATE OF BIRTH

A CQUI SI T I ON COST , P I M PROV EM ENT S

ACQUISITION COST, P

AMOUNT, P

DATE OF ACQUISITION/ CONNECTION

NAME/ADDRESS OF OFFICE

Signature

_ day of _________, 20_____ affiant exhibiting his/her

(Person Administering Oath)