Sworn Statement Of Assets Liabilities And Net Worth
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4SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of ________________________________
(Required by R.A. 6713)
Note: Husband and wife who are both public officials and employees may file the required statements jointly or separately.
Joint Filing
Separate Filing
Not Applicable
DECLARANT:
POSITION:
(Family Name)
(First Name)
(M.I.)
AGENCY/OFFICE:
ADDRESS:
OFFICE ADDRESS:
SPOUSE:
POSITION:
AGENCY/OFFICE:
(Family Name)
(First Name)
(M.I.)
OFFICE ADDRESS:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NAME
DATE OF BIRTH
AGE
ASSETS, LIABILITIES AND NETWORTH
(Including those of the spouse and unmarried children below eighteen (18)
years of age living in declarant’s household)
1. ASSETS
a.
Real Properties*
DESCRIPTION
KIND
LOCATION
ASSESSED
CURRENT FAIR
ACQUISITION
ACQUISITION COST
(e.g. lot, house and
(e.g. residential,
VALUE
MARKET VALUE
lot, condominium
commercial, industrial,
(As found in the Tax Declaration of
and improvements)
agricultural and mixed
YEAR
MODE
Real Property)
use)
Subtotal:
b. Personal Properties*
DESCRIPTION
YEAR ACQUIRED
ACQUISITION COST/AMOUNT
Subtotal :
TOTAL ASSETS (a+b):
2. LIABILITIES*
NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
TOTAL LIABILITIES:
NET WORTH : Total Assets less Total Liabilities =
* Additional sheet/s may be used, if necessary.
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