SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

(Required by R.A. 6713)

Note:Husband and wife who are both public officials and employees may file the required statements jointly or seperately.

Joint Filing Separate Filing

Name Position/ Income(Family Name) (First Name) (M.I.) Agency/ Office

Address Office Address

Spouse Name Position(Surname) (First Name) (M.I.) Office

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANTS HOUSEHOLD

Name Date of Birth Age

ASSETS, LIABILITIES AND NETWORTH

1. ASSETSa. Real Properties

Description Kind LocationAcquisition

Year Mode

b. Personal and other PropertiesKind Year Acquired Acquisition Cost

2. LIABILITIES (Loans, Mortgages, etc.)Nature Name of Creditor Amount

Total

NET WORTH (Total Assets (1a + 1b) Less Total Liabilities (2) Total

As of December 2013

(Including those of the spouse and unmarried children below eighteen (18) years of age living in declarant's household)

Current Fair Market Value

AssessedValue

(Note: Please use additional forms/ sheets if necessary. Also, please reproduce this form back to back)

B. BUSINESS INETERESTS AND FINANCIAL CONNECTIONS

Yes No If Yes, give particulars:

Name Address

N O N E

C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

Yes No If Yes, give particulars:

Name Position Relationship Name/ Address of Office

Date:

(Signature of Declarant) (Signature of Co-Declarant)

Gov't Issued ID: Gov't Issued ID:

ID #: ID #:Date of Issue: Date of Issue:

(Person Administering Oath)

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?

Name of Firm/Company

Nature of BusinessInterest and/ or

Financial Connection

To the best of your knowledge, are you related within the fourth degree of Consanguinity or of affinity to anyone working in the government?

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 children below 18 years of age and names of my relatives in the government as of December 2010, as required by in accordance with Republic Act 6713.

I hereby authorize the Ombudsman or his duly authorized representatives 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 interests and financial connections, to include those of my spouse and my 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.

SUBSCRIBE AND SWORN to before me this ______ day of _______________, affiant exhibiting his/ her Government Issued ID as indicated above.

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

(Required by R.A. 6713)

Husband and wife who are both public officials and employees may file the required statements jointly or seperately.

Not Applicable

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANTS HOUSEHOLD

Age

ASSETS, LIABILITIES AND NETWORTH

Acquisition Cost

Land; Bldg., etc. Improvements

Total P -

Acquisition Cost

Total P -

Amount

P -

P -

December 2013

(Including those of the spouse and unmarried children below eighteen (18) years of age living in declarant's household)

(Note: Please use additional forms/ sheets if necessary. Also, please reproduce this form back to back)

B. BUSINESS INETERESTS AND FINANCIAL CONNECTIONS

E

C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

Name/ Address of Office

(Signature of Co-Declarant)

(Person Administering Oath)

Do you have any business interests and other financial connections including those of your spouse and unmarried children below 18

Nature of BusinessInterest and/ or

Financial Connection

Date of Acquisitionor Connection

To the best of your knowledge, are you related within the fourth degree of Consanguinity or of affinity to anyone working in the

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 children below 18 years of age and names of my relatives in the government as of December 2010, as required by in accordance with Republic Act 6713.

I hereby authorize the Ombudsman or his duly authorized representatives 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 interests and financial connections, to include those of my spouse and my 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.

SUBSCRIBE AND SWORN to before me this ______ day of _______________, affiant exhibiting his/ her Government Issued ID as