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_________________________________________

Unit/ Office

SWORN STATEMENTS OF ASSETS AND LIABILITIES AND NET WORTH

DISCLOSURE OF BUSSINESS INTERESTS AND FINANCIAL CONNECTIONS, AND

IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

As of ___________________________

(Required by RA No. 6713)

Name: ___________________________________________________________________________________

(Surname/ First name/ M.I.) (Rank/ Serial No./ Br. of Svc)

Date of Birth: ____________________________ Place of Birth: ____________________________________

Address: _________________________________________________________________________________

Date of Appointment/ CAD/ Enlistment: _______________________________________________________

Office Address: ____________________________________________________________________________

Position/ Designation: ______________________________________________________________________

Spouse Name: __________________________________ Position/ Office:____________________________

(Surname/ First name/ M.I.)

Unmarried Children below 18 years of age

Name Date of Birth Name of School/ Occupation

A. ASSETS, LIABILITIES AND NET WORTH

1. ASSETS

a. Personal Properties:

NATURE Acquisition Repairs/ Improvements Total Cost

Mode Year

Acquire

d

Cost Prev Yrs.

(Accum)

Current

Year

Cash and Bank Deposits

Receivables

Investments (Bus, Stocks)

Fur, Fixtures & Appliances

Jewelry and Books

Motor Vehicles

Other Assets (Specify)

Total ------------ P________________

b. Real Properties:

Nature/ Location Mode of

Acquisi-

tion

Year

Acquire

d

Market

Value

Acquisition

Cost

Repairs/ Improvements Total Cost

Prev Yrs. Current

Year

House and Lot

Agri Lands

Apartments/ Bldgs

Others (Spacify)

Total ------------ P________________TOTAL ASSETS (Personal & Real) ------------------- P________________

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2. LIABILITIES

CREDITORS NATURE YEAR

Incurred

TERM AMOUNT AMORTI-

ZATION

BALANCE

Loans/ Banks/ Financial

Institution

Loans Personal

Other Accounts Payable

Total ---------------- P____________________

NET WORTH: Total Assets (1 & !b) Less Total Liabilities (2) --------------------P___________________

3. My family income and other sources of funds composed of salary, allowances, bonus, dividends,

sale/ rentals of property, inheritance, financial aids, donations, etc., including those of my spouse and

children below 18 years during the calendar year this statement is filed are as follows:

COMPOSITION NATURE SOURCE AMOUNT

Filers Gross Compensation

Income

Spouse Gross Compensation

Income

Net Income from Bus Investments

Professional Fees and/ or SimilarFees

Financial Aids/ Assistance

Inheritance

Proceeds from Sale of Assets

Other Income/ Source of fund

Total ---------------- P____________________

4. The income tax I paid during the preceding calendar year to include income tax withheld for the

current calendar year for which this statement is made amounted to P______________________ .

5. My/ our personal/ family expenses composed of food , clothing, schooling, medical, entertainment,

insurance, interest paid of loans, educational plans, electrical/ water bills, rentals, other taxes etc.

amount to P_______________________.

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B. DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS

Business interest and financial connection including those of my spouse and unmarried children

below 18 years of age living in my household are the following:

NAME NAME OF FIRM ADDRESS Nature of Business

Interest and/ or

Financial

Connection

Date of

Acquisition/

Connection

C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

My relatives within the fourth degree of consanguinity or affinity/ to any one working in the

government are as follows:

Name Position Relationship Name/ Address of Office

I am making this statement in compliance with R.A. 6713. I am (check the appropriate statement):

________________ a. A new member/ employee of the AFP.

________________ b. Already a member/ employee of the AFP.

________________ c. Leaving the service.

I hereby certify to the best of my knowledge and information, that these are true statements of my

assets, liabilities, networth, business interest, and financial connections, including those of my spouse and

unmarried children below 18 years of age and names of relatives in the government service as of

____________________ as required by and in accordance with Republic Act 6713.

Date: ____________________

____________________________________

(Print Name/ Signature)

Community Cert. No. _________________

Issued at ___________________________

Date Issued _________________________

TIN ___________________

SUBSCRIBED AND SWORN to before me this _____ th day of

_______________________________ affiant exhibiting to me his/ her Community Tax Certificate as

indicated above.

____________________________________

(Person Administering Oath)

____________________________________

(Duty & Unit Assignment)