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SWORN STATEMENT OF ASSETS LIABILITIES AND NET WORTH DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE As of December 31 Required by Republic Act No. 6713 Name Surname First Name M. I. Address Name of Spouse Position/Income Office Office Address Position/Occupation Unmarried Children below 18 years of age Date of Birth A. ASSETS LIABILITIES AND NET WORTH 1. ASSETS a* Real Properties Acquisition Cost Kind Location Year Mode of Acquired Acquisition Assessed Value Current Fair Market Value Land Building etc* Improvements TOTAL 1a P b. Personal and Other Properties Year Acquired TOTAL ASSETS 1a 1b 2. LIABILITIES Loans Mortgages etc* Nature Amount TOTAL 2 P NET WORTH Total Assets 1a 1b Less Total Liabilities 2 NOTE Please use additional forms / sheets if necessary. Also please reproduce this form back to back. B. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS Do you have any business interests 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 of Firm/ Company Nature of Business Interest and/or Financial Connections Date of or 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 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 net worth business interests and financial connections including those of my spouse and unmarried required by and in accordance with Republic Act 6713. I hereby authorized the Ombudsman or his 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 office in government. Date Signature of Spouse TIN Com* Tax Cert. No* Issued at Issued on Signature of Employee SUBSCRIBED AND SWORN TO before me this day of 20 affiant exhibiting his/her Community Tax Certificate as indicated above. I. Address Name of Spouse Position/Income Office Office Address Position/Occupation Unmarried Children below 18 years of age Date of Birth A. ASSETS LIABILITIES AND NET WORTH 1. ASSETS a* Real Properties Acquisition Cost Kind Location Year Mode of Acquired Acquisition Assessed Value Current Fair Market Value Land Building etc* Improvements TOTAL 1a P b. ASSETS LIABILITIES AND NET WORTH 1. ASSETS a* Real Properties Acquisition Cost Kind Location Year Mode of Acquired Acquisition Assessed Value Current Fair Market Value Land Building etc* Improvements TOTAL 1a P b. Personal and Other Properties Year Acquired TOTAL ASSETS 1a 1b 2. LIABILITIES Loans Mortgages etc* Nature Amount TOTAL 2 P NET WORTH Total Assets 1a 1b Less Total Liabilities 2 NOTE Please use additional forms / sheets if necessary.

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