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Statement of Assets and Liabilities Form 1994

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Statement of Assets and Liabilities Form 1994 Powered By Docstoc
					                                                                                               1(Revised, 1994)
                 SWORN STATEMENTS OF ASSET, LIABILITIES AND NETWORTH
             DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
                  AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT
                                As of December 31, _____
                                  (Required by R.A. 6713)

Name      _____________________________             __        Position/Income : ______________________
         (Surname)         (First Name)           (MI)        Office : ________________________________
Address _________________________    __ _                     Office Address : __________________________
_________________________________________                     ____________________________________
__________________________________________
Spouse Name ______________      __________                    Position ________________               ______
               (Surname)          (First Name)      (MI)      Office ____________________                 _

                                  Unmarried Children Below 19 years of age
                         Name                                           Date Of Birth




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

                                                                     Current           Acquisition Cost
                             Year          Mode of       Assessed
  Kind        Location                                              Fair Market     Land,
                            Acquired      Acquisition     Value                               Improvements
                                                                      Value       Bldg, etc.




                                                                                  TOTAL: Php
   b. Personal and other Properties

               Kind                              Year Acquired                     Acquisition Cost




                                                                                  TOTAL: Php
2. LIABILITIES (Loans, Mortgages, etc)

                         Nature                                               Amount




                                                                                  TOTAL: Php
NETWORTH (Total Assets (1a + 1b)
          Less Total Liabilities                                                  TOTAL: Php
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         Nature of Business Interest    Date of Acquisition or
                                Firm/Company       and/or Financial Connection         connection




               B. IDENTIFICATION OR 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 my relatives in the government as of
December 31, 2005, as required by and in accordance with Republic Act 6713.

       I hereby authorize 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 my show my assets, liabilities, networth, business interest 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 first assumed office in government.



(Date)        _____________                   .


_____________________________________                             ______________________________
          Signature of Spouse                                           Signature of Employee


TIN    _______________________________             TIN    _______________________________
Com. Tax Cert No. _____________________            Com. Tax Cert No. __________ ___________
Issued at _____________________________            Issued at _______________ ______________
Issued on_____________________________             Issued on _____________________________


        SUBSCRIBE AND SWORN TO before me this ___________________________________ day
of _________________, _________________ affiant exhibiting his Community Tax Certificate as
indicated above.




                                           _________________________________________________
                                                         (Person Administering Oath)

				
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