Revised as of January 2015
Per CSC Resolution No. 1500088
Promulgation on January 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES, AND NET WORTH
As of _December 31, 2023
(Required by R.A. No. 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:_PHILIPPINE NATIONAL POLICE
ADDRESS:_________________________________ __ OFFICE ADDRESS:_DCPO - ________________
____________________ _______________
SPOUSE :____________________________ ________ POSITION:_______________________________
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:__________________________
OFFICE ADDRESS:___________ ______________
UNMARRIED CHILDREN BELOW EIGHT (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 childrenbelow eighteen (18)
years of age living in declarant’s household)
1. ASSETS:
a. Real Properties*
KIND
DESCRIPTION CURRENT FAIR ACQUISITION
(e.g. residential, EXACT ASSESSED
(e.g Lot, House and MARKET VALUE ACQUISITION COST
commercial, industrial LOCATION VALUE
Lot, Condominium
agricultural and Mixed (As found in the Tax Declaration of
and Improvements) YEAR MODE
use) Real Property)
Subtotal: P_____________
b. Personal and other Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT
Subtotal: P_____________
TOTAL ASSETS (a+b): P______________
Page 1 of _____
2. LIABILITIES*
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
TOTAL LIABILITIES: P _____________
NETWORTH: Total Assets less Total Liabilities = P________________
*Additional sheet/s may be used if necessary.
BUSINESS INTEREST AND FINANCIAL CONNECTIONS
(of Declarant/Declarants spouse/ Unmarried Children Below Eighteen (18) years of Age living in Declarant’s Household)
I/We do not have any business interest or financial connection
DATE OF
NAME OF
NATURE OF BUSINESS ACQUISITION OF
ENTITY/BUSINNES BUSINESS ADDRESS
INTERESTS &/OR FINANCIAL INTEREST OR
ENTERPRISE
CONNECTION CONNECTION
RELATIVES IN THE GOVERNMENT SERVICE
(Within the Fourth Degree of Consanguinity or Affinity Include also Bilas, Baiao and Inso)
I/We do not know of any relative/s in the government service.
NAME OF RELATIVE RELATIONSHIP POSITION NAMEOF AGENCY/OFFICE AND ADDRESS
I hereby certify that these are true and correct statements of my assets, liabilities, net worth business
interest and financial connections, including those of my spouse and unmarried children below eighteen (18)
years of age living in my household, and that to the best of my knowledge the above enumerated are names of
my relatives in the government within the fourth civil degree of consanguinity or affinity.
I hereby Authorize the Ombudsman or his/her duly authorized representative to obtain and to secure
from all appropriate government agencies, including the Bureau of Internal Revenue, such documents that may
shown my assets, liabilities, net worth, business interest and financial connections, to include those of my
spouse and unmarried children below 18 years of age living with me in my household covering previous years to
include the year I first assumed office in the government.
Date: ______________2024
_________________________ ____________________________
(Signature of Declarant) Signature of Co-Declarant/Spouse
Government Issued ID:_ ________________ Government Issued ID:_____________
ID No.: ____________________ ID No.: _______________
Date Issued: ___________________ Date Issued: _____________
SUBSCRIBED AND SWORN to before this ________day of ____________ ____ affiant exhibiting to me
the above-stated government issued identification card.
_______________________
(Person Administering Oath)
