Statement Of Assets, Liabilities And Net Worth And Disclosure Of Business Interests, Financial Connections And Relative/s In The Government Service - Supreme Court
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2STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
AND DISCLOSURE OF BUSINESS INTERESTS, FINANCIAL CONNECTIONS
AND RELATIVE/S IN THE GOVERNMENT SERVICE
As of December 31, ________
(Required by R.A. Nos. 3019 and 6713)
(Note: Husband and Wife who are both public officials or employees may
file the required statements jointly or separately.)
Jointly filed.
Separately filed.
Name _______________________________________________
Position _________________________________________
(Surname)
(First Name)
(Middle Initial)
Office
_________________________________________
Address ____________________________________________
Office Address __________________________________
____________________________________________
___________________________________________
I am married.
I am not married.
Spouse ___________________________________________
Position _________________________________________
(Surname)
(First Name)
(Middle Initial)
Office
_________________________________________
Office Address __________________________________
__________________________________________
Unmarried Children below 18 years of age living in his/her household: (use additional sheet/s, if necessary)
Name
Date of Birth
1. _____________________________________________
___________________________________
2. _____________________________________________
___________________________________
3. _____________________________________________
___________________________________
I have no children below 18 years of age living in my household.
ASSETS, LIABILITIES AND NET WORTH
I. ASSETS (including that of declarant’s spouse and unmarried children below 18 years of age living in his/her
household)
A. REAL PROPERTY/IES (use additional sheet/s, if necessary)
KIND
NATURE OF
LOCATION
ACQUISITION
ASSESSED
FAIR
ACQUISITION COST*
(
PROPERTY
VALUE
MARKET
Res./Comm./
MODE
YEAR
Land,
Improvement/s
Agri., etc.)
(Paraphernal,
VALUE
Building,
conjugal or
others
)
community
TOTAL: ________________
B. PERSONAL PROPERTY/IES AND OTHER ASSETS (use additional sheet/s, if necessary)
TANGIBLE
ACQUISITION
ACQUISITION COST*
MODE
YEAR
INTANGIBLE
TOTAL: _____________________
*For computation purposes, use acquisition cost. Properties of unmarried children below 18 years of age living in
his/her household shall be excluded as well as the paraphernal/exclusive properties of spouse, in case of separate
filing.
TOTAL ASSETS (A+B)=___________________________
II. LIABILITIES (including that of declarant’s spouse and unmarried children below 18 years of age living in his/her
household)
NATURE
NAME OF CREDITOR/S
*OUTSTANDING BALANCE
TOTAL: ___________________________
(use additional sheet/s, if necessary)
*In the computation of outstanding balance, properties of unmarried children below 18 years of age living in
his/her household shall be excluded as well as the paraphernal/exclusive properties of spouse, in case of separate
filing.
NET WORTH (III)
III. NET WORTH (TOTAL ASSETS (I) LESS TOTAL LIABILITIES (II) =
TOTAL NET WORTH: _____________________________
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