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swoRN STATEMENT OF ASSETS, LIABTLITIES AIiID NET lITORTHAs of

(Required bD, R'A. 6713)

Noto: Husband anduife:ullwanebothpublboJficinlsand,emplogee)smct1frlethereqhed,stotements.ybintlgorseparatelg.

0 Joint Filing 0 Separate Filing 0 Not Applicable

DECLARANT:

ADDRTBS:

SPOUSE!

(Family Name) (First Name) (M.r,)

PIOSITION:

'AorNcv/oFt'Icp:, ol'ngEADDRESS:

FOSITIOI{:-AGEilCY/OIFICE:

OFFICE ADDRES$:

(Family Name) (First Name) (M.I.)

UI{MARRIEp CHILpREN BELOW EIGHTEEIV (l8lYEARS OF AcD LrVrNc II{ DECLARATIT'S HOUSEHOLD

ilAilE,

DATEOTBIRTH AGE

ASSETS. LIABILITIES AND NETWORTH(Including tlnse of the spouse and. unmarried children below eighteen (18)

Aears of age liuing in declarant,s lnusehald)

1. ASSETS

a. Real Propertles* i

Subtotal:b. Perconal ProperHet*

Subtotal:I0TALAESIilE (a+bt:

LIABILITIES*

TOTAL LIABILITIES:

Additio)at sh.eet/ s mag be used,

: Total Astets less Total Llablllfies = . IVET WORTTI

{ rB@.ssary.,

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BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

(of Declarant / Declarant's spouse/ unntanied Child.ren Below Eighteen (18) gears of Age Liuing in Declarant's Houselwld,)

0 I/ We d.o not Lutue ang business interebt or firruncial connectiorL

, RELATTYES IN TriE GOVERN1VfENT'SPRVICE

Within tle lourth Degree of consanguinit! or AffLntfu. Includ.ealso Bilas, Balae and. Inso)

A I/ We do,iot kruou of arry relatiue/ s it the gouenlment seruice)

I heleby certify that these are true and coflect statements of my assets, liabilities, net worth,business intcrests zurd financial connections, including those of my spouse ancl unmarried children beloweighteen (18) years of age living in my household, and that to the trest of my knowledge,.the above'-.enumeratcd arc nalnes of my relatives in the government within the fourth civil degree of consanguinity oraflinity.

'

I hcleby authorize the Ombudsman or his/her duly authorized representative to obtain andsecllre from a-11 appropriate government a$encies, includi.ng the gureau of lnternal Revenue suchdocuments that may show m-v asse[s, liabilities, net worth, business interests and financial connections,to include those of my

"pou"'"and unmarried childrei ueto* 18 ygars of age living with me in my

householcl coveringpreviousyears'toinclucletheyear Ifirst assumecl oni..i, goiernmen"t.

Date:'

n

( Sig r wture of De clarant) (Srgnature of Co-Declarant/ Spouse)

Gotrernment Issued ID:lD No.:

Date Issued:

SUBSCRIBED AI{D SWORN to beforegoverrunent issued identification card.

me this _day of .--, arfiant exhibiting to me the above_stated

Government Issued ID:ID No,: i

Date Issued: :

(Person Administertng O ath)