Professional Documents
Culture Documents
DECLARANT: ____________________________________________
___________________________
(Family Name)
(First Name)
___________________________
Position:
(M.I)
Agency Office:
Office Address:
__________________________
Address: ________________________________________________
___________________________________
________________________________________________
Spouse: _________________________________________________ Position:
___________________________
(Family Name)
(First Name)
(M.I)
Agency Office:
___________________________
Office Address:
__________________________
________________________________
- - -
NAME
__________________________
__________________________
__________________________
__________________________
__________________________
__________________________
DATE OF BIRTH
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
AGE
_________________
_________________
_________________
_________________
_________________
_________________
(Including those of the spouse and unmarried below eighteen (18) Years of age living in declarants
household)
1. ASSETS
a. Real Properties
DESCRIPTI
KINDS
LOCATI
Eg.
Residential,
ON
ON
commercial,
Eg. Lot house,
condominiums and
improvements)
agricultural, and
mixed use)
ASSESS CURREN
ED
T FAIR
VALUE
VALUE
As found in the Tax
Declaration of Real Property
ACQUISITION
YEAR
ACQUIS
ITION
COST
MODE
Subtotal: P
____________________
b. Personal and Other Properties
Kind
YEAR ACQUIRED
ACQUISITION COST
Subtotal:
P____________________
TOTAL ASSETS (a + b): P
____________________
2. LIABILITIES (Loans, Mortgages, etc.)
NATURE
NAME OF CREDITORS
AMOUNT
Total Liabilities: P
__________________
Do you have any business and other financial connection including these your spouse
and unmarried below 18 years of age living with you in your household / / Yes / / No,
If yes, give particulars:
NAME OF
BUSINES
NATURE OF BUSINESS
DATE OF
ENTITY/BUSINESS
S
INTEREST AND/OR
ACQUISITION
ENTERPRISES
FINANCIAL CONNECTIONS
OR
CONNECTION
I hereby certify that those are true and correct statements of my assets, liabilities, net worth,
business interest 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 aboveenumerated are names of any relatives in the government within the fourth civil degree of consanguinity
or affinity.
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, liabilities, net worth, 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 past years
to include the year I first assumed office in government.
___________________________________________
______________________________________________
Signature of Declarant
Declarant/spouse
Government Issued I.D: _______________________
________________________
I.D. No. ____________________________________
Issued on: __________________________________
___________________________________
Signature
Government
Issued
of
Co-
I.D:
___________________________________________
Personal Administering Oath