Assets And Liabilities
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SWORN STATEMENTS OF ASSETS, LIABILITIES AND NETWORTH DISCLOSURES OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE As of December 31, 2003 (Required by RA 6713)
Name
:
Address
:
Position/Income: Office: Office Address:
Spouse Name
:
Position:
(Surname)
(Surname)
(First Name)
(First Name)
(M.I.)
Office:
(M.I.)
Unmarried Children Below 18 Years of Age Name
Date of Birth
A. ASSETS, LIABILITIES AND NETWORTH 1. ASSETS a) Real Properties Kind
Location
Year Mode of Assessed Value
Acquired Acquisition
Current Fair Market Value
Acquisition Cost Land/Bldg./etc Improvements
Total: b) Personal and other Properties
KIND
YEAR ACQUIRED
ACQUISITION COST
Total: 2) LIABILITIES (Loans, Mortgages,etc)
Total: NETWORTH : Total Assets ( 1a + 1b ) Less Total Liabilities (2)
TOTAL:
BUSINESS INTEREST AND FINANCIAL CONNECTION
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 particular:
NAME
NAME OF FIRM/ Company
Address
Nature of Business Interest and /or
Date of Acquisition or Connection
C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE To the best of your knowledge, are you related within the fourth degree of consaguinity or of affinity to anyone working in the government? Yes No If Yes give particulars:
NAME
Position
Relationships
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,__________, 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 may 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 year I first assumed office in the government.
Date
Res. Cert. No: Issued at : Date Issued :
Signature of Employee
TIN: B:______________________________
SUBSCRIBED AND SWORN to before me this ____________________day of _________ Residence Tax Certificate as indicated above.
JAIME A. PAJARILLAGA Schools Administrative Officer III
Name
:
Address
:
Position/Income: Office: Office Address:
Spouse Name
:
Position:
(Surname)
(Surname)
(First Name)
(First Name)
(M.I.)
Office:
(M.I.)
Unmarried Children Below 18 Years of Age Name
Date of Birth
A. ASSETS, LIABILITIES AND NETWORTH 1. ASSETS a) Real Properties Kind
Location
Year Mode of Assessed Value
Acquired Acquisition
Current Fair Market Value
Acquisition Cost Land/Bldg./etc Improvements
Total: b) Personal and other Properties
KIND
YEAR ACQUIRED
ACQUISITION COST
Total: 2) LIABILITIES (Loans, Mortgages,etc)
Total: NETWORTH : Total Assets ( 1a + 1b ) Less Total Liabilities (2)
TOTAL:
BUSINESS INTEREST AND FINANCIAL CONNECTION
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 particular:
NAME
NAME OF FIRM/ Company
Address
Nature of Business Interest and /or
Date of Acquisition or Connection
C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE To the best of your knowledge, are you related within the fourth degree of consaguinity or of affinity to anyone working in the government? Yes No If Yes give particulars:
NAME
Position
Relationships
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,__________, 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 may 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 year I first assumed office in the government.
Date
Res. Cert. No: Issued at : Date Issued :
Signature of Employee
TIN: B:______________________________
SUBSCRIBED AND SWORN to before me this ____________________day of _________ Residence Tax Certificate as indicated above.
JAIME A. PAJARILLAGA Schools Administrative Officer III
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