Statement Of Assets, Liabilities And Net Worth And Disclosure Of Business Interests, Financial Connections And Relative/s In The Government Service - Supreme Court Page 2
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2AMOUNT AND SOURCES OF GROSS INCOME
(ALL amounts received from ALL sources for the preceding calendar year)
NATURE
SOURCES
AMOUNT
(salary/income, business, etc.)
(use additional sheet/s, if necessary)
TOTAL: _______________________
AMOUNT OF PERSONAL AND FAMILY EXPENSES
(for the preceding calendar year)
PERSONAL EXPENSES
ESTIMATED
FAMILY EXPENSES
ESTIMATED
AMOUNT
AMOUNT
(use additional sheet/s, if necessary)
TOTAL : _______________
TOTAL : ______________
AMOUNT OF INCOME TAXES PAID
(for the preceding calendar year)
NATURE
AMOUNT
Compensation
Business Income
Other Income
(use additional sheet/s, if necessary)
TOTAL : _____________________________
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(Declarant/Spouse/Unmarried Children below 18 years of age living in the household of declarant)
(Use Additional Sheet/s, if necessary)
I/We don’t have any business interests and financial connections.
Name of Entity/Business
Business Address
Nature of Business
Date of Acquisition of
Enterprise
Interest and/or
Interest or Connection
Financial Connection
RELATIVE/S IN THE GOVERNMENT
(Up to the 4
th
civil degree of relationship, either by consanguinity or affinity, including bilas, inso and balae)
(Use Additional Sheet/s, if necessary)
I/We don’t know of any relative/s in Government.
Name of Relative
Relationship
Position
Name of Office/Address
I/We hereby certify that these are my/our true and detailed assets, liabilities, net worth, amount and sources of income,
personal and family expenses, amount of income taxes paid, business interests, and financial connections, including those of my spouse
and my/our children below 18 years of age living in my household, and the name/s of my relative/s in the Government, as of December
31, __________, as required by and in accordance with Republic Act No. 3019 and 6713.
I/We hereby authorize the Ombudsman or his duly authorized representative to obtain and secure from all appropriate
agencies, including the Bureau of Internal Revenue, such documents that may show such assets, liabilities, net worth, business
interests, and financial connections, including those of my spouse and my/our children below 18 years of age living in my household,
covering previous years, and if possible, including the year I/we first assumed office in Government.
I/We further undertake to produce all supporting documents for each of the entries herein made when required.
Declarants’ Signature: __________________________
______________________________
Date: ____________________________
Date: ____________________________
(For Separate Filing) Spouse’s Signature: _________________________
Date: ____________________________
SUBSCRIBED AND SWORN TO before me on this _______ day of ______________, 20______, affiant(s) exhibiting his/her/their tax
identification number(s) _______________________________ and employee number(s) ______________________________.
______________________________
(Person Administering Oath)
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