SALN Revised 2013 SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH Asof - _—_ (Required by RA. 6713) Note: Husband and wife who are both publi officials and employees may file the required statements jointly or separately @ Joint Filing 8 Separate Filing 9 Not Applicable DECLARANT: - POSITION: _ - ~ Family Name) Tris Namer ST) AGENCY/OFFICE: ADDRESS: _ OFFICE ADDRESS: - SPOUSE: PosITIow: - - ‘AGENCY /OFFICE: ‘OFFICE ADDRESS: UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD vane bate oF nina foe ASSETS, LIABILITIES AND NETWORTH (inctuding those ofthe spouse and unmarried cldren below eighteen (18) tears of age hung in declarant’ household) 1. ASSETS: a Real Propertiost puscurnon| xm | vocariow] assessep | cummewr rain | acqusrion | ACQUISTION cost ‘emia’ | teri van | sunesr wae Esmee | sats onigetemeens | waa | woos b. Personal Properties" 2. NAME OF CREDITORS “TOTAL LIABILITIES: NET WORTH : Total Assets less Total Liabilities = * Additional sheet/s may be used, if necessary. Page | ofSALN Revised 2013 BUSINESS INTERESTS AND FINANCIAL CONNECTIONS {of Declarant /Dectarant's spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarant’s Household) 6 1/We do not have any business interest or financial connection. MAME OF ENTITY/BUSINESS ‘BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF ENTERPRISE INTEREST &/OR FINANCIAL | INTEREST OR CONNECTION ‘CONNECTION RELATIVES IN THE GOVERNMENT SERVICE [Within the Fourth Degree of Consanguinity or Affinity. Inchude also Bilas, Balae and nso} 8 1/ We do not know of any relative/s in the government service) RELATIONSHIP Posrrion NAME OF RELATIVE, [NAME OF AGENCY/OFFICE AND ADDRESS Thereby certify that these are true and correct statements of my assets, liabilities, net worth, business interests 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 secure from all appropriate government agencies, including the Bureau of Internal Revenue such documents that may show my assets, liabilities, net worth, business interests 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 government. Date: (Signature of Declarant) Government Issued ID: IN Date Issued: SUBSCRIBED AND SWORN to before me this __day of government issued identification card. Signature of Co-Dedlarani/Spouse) Government Issued Ib: 1D No. Date Issued: affiant exhibiting to me the above-stated (Person Administering Oath) Page 2of __SALN Revised 2013 SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of __ (Sample additional sheet/s for the exclusive properties of the declarant’s spouse and unmarried children below eighteen (18) years of age living in declarant’s household} NAME: POSITION: amily Namel ‘(First Name] wey AGENCY /OFFICE: ASSETS, LIABILITIES AND NET WORTH 1. ASSETS Real Properties ‘NAME OF CREDITORS: ‘OUTSTANDING BALANCE BUSINESS INTERESTS AND FINANCIAL CONNECTIONS AME OF ENTITY /BUSIVESS BUSINESS ADDRESS NATURE OF BUSINESS. DATE OF ACQUISITION OF ENTERPRISE INTEREST &/OR FINANCIAL | INTEREST OR CONNECTION ‘CONNECTION Page ofSALN Revised 2013 SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH Asof _ (Sample additional sheet/s for the declarant) NAME: Postrion: ‘Family None) (Frame) (HUTT ——AGENCY/oFFICE: - ASSETS, LIABILITIES AND NET WORTH 1. ASSETS a. Real Properties pescripnion| mp | Locamion| assessen | cunnenrram | ACQUISITION | ACQUISITION cost Newent | oem vawue | warscer VALUE YEAR | MODE sc improvenens | Sgciarl and med Ussund in tieTax Dechraton ol | eal ope | ‘TOTAL LIABILITIES: BUSINESS INTERESTS AND FINANCIAL CONNECTIONS ‘NAME OF ENTITY /BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF ENTERPRISE INTEREST &/OR FINANCIAL | INTEREST OR CONNECTION ‘CONNECTION Page of