Baseline Declaration Form (5/19/2014)

SWORN STATEMENT OF ASSETS, LIABILITIES, AND NET WORTH

DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE (Required by R.A. N. !"#$%
A& ' (((((((((((((((((((((( (Baseline Declaration)
Note: Please write your responses in ALL CAPITAL letters using ONLY BALL PEN to avoid blotting.
A. DECLARANT)S *ERSONAL INFORMATION AND EM*LO+MENT
*or !oint "iling# $a%e & entries "or Na$e# Position# 'e(larant)s Annual *ross +alary# Na$e o" Agen(y# and O""i(e Address
,Annual *ross +alary re"ers to ALL a$ounts re(eived by de(larant "ro$ *overn$ent servi(e
L,&- N,.e Fir&- N,.e Midd/e N,.e
H.e Addre&& *&i-i0 De1/,r,0-)& A00u,/ Gr&& S,/,ry
, Annual *ross a$ily In(o$e re"ers to in(o$e o" de(larant# spouse# and de(larant)s (-ildren below ./ years o" age living in de(larant)s -ouse-old
N,.e ' A2e01y3O''i1e O''i1e Addre&& A00u,/ Gr&& F,.i/y I01.e
I am married. I am not married. I have no children below 18 years of age living in my household.
Spouse Information:
Name: !osition: "ompan#:
C4i/dre0 ' De1/,r,0- Be/5 #6 +e,r& ' A2e Li7i02 i0
Hu&e4/d ' De1/,r,0- (U&e ,ddi-i0,/ &4ee- i' 0e1e&&,ry%
D,-e ' Bir-4
B. ASSETS, LIABILITIES, AND NET WORTH
Instru(tion "or all assets: 'e(lare assets w-et-er t-e de(larant0spouse0(-ild is t-e legal owner 1na$e
appearing on t-e instru$ent o" title2 or t-e bene"i(ial owner 1property is in t-e na$e o" anot-er person but
owners-ip pertains to de(larant0spouse0(-ild# under a trust arrange$ent2.
#. Re,/ *r8er-ie& ,0d Ve4i1/e& ' De1/,r,0-3S8u&e3De1/,r,0-)& C4i/dre0 Be/5 #6 +e,r& ' A2e
Li7i02 i0 -4e Hu&e4/d ' De1/,r,0-, re2,rd/e&& ' ,.u0- (U&e ,ddi-i0,/ &4ee- i' 0e1e&&,ry%
I have no real properties to declare owned by me/ my spouse/my children below 18 years of age living in my household
I have no vehicles to declare owned by me/my spouse/my children below 18 years of age living in my household
Kind of Real Property/

Type of Vehicle and
plate no.
Location of Real
Property/
Cert No. and Place
of Reg of
Vehicle
Acquisition
sti!ated
"air #ar$et
Value %Php&
Assessed
Value %Php&
#ode 'ear Cost %Php& 1Not Appli(able to
3e-i(les2
Total
:
9. I07e&-.e0-&, O-4er *er&0,/ *r8er-ie&, ,0d Li,bi/i-ie& ' De1/,r,0-3S8u&e3De1/,r,0-)&
C4i/dre0 Be/5 #6 +e,r& ' A2e Li7i02 i0 -4e Hu&e4/d ' De1/,r,0-
I have no investments to declare owned by me/my spouse/my children below 18 years of age living in my household
I have no personal properties to declare owned by me/my spouse/my children below 18 yrs of age living in my household
I have no liabilities to declare pertaining to me/my spouse/my children below 18 years of age living in my household
Instru(tions: Declare each Asset Item (Investment and Other Personal Property) with a fair market value of Php50,000 or more as
of the date of declaration, even if the same was acuired at no cost or at less cost! Declare each "ia#ility Item with an outstandin$
#alance of Php50,000 or more as of the date of declaration! Items with less value may #e declared in lump sum as %Others!&
'owever, if %Others& amounts to more than Php (00,000, each item must #e listed! Put a check mark on the items to #e declared,
and make the correspondin$ entry for the actual Acuisition )ost or Outstandin$ *alance, as applica#le!
(.).* +n,est!ent +te! Acquisition Cost (.).* +n,est!ent +te! Acquisition Cost
Stoc$s (e%uit# pai&) !re'nee& plans (premiums p&)
Bon&s (ime &eposits
)utual fun&s )one# mar$et placements
(rust fun&s *%uit# in partners+ips
!ri,ate insurance (premiums p&) -ptions
*&ucational plans (premiums p&) -t+ers
+otal Php,
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Baseline Declaration Form (5/19/2014)
(.).) -ther Personal Property Acquisition Cost (.).. Lia/ility -utstanding (alance
"as+ on +an&/Ban$ accounts !ersonal loans
/ecei,a0les Ban$ loans
Deposits/a&,ance& pa#ments on
leases/rentals
1ccounts pa#a0les
Furniture2 anti%ues 3SIS2 !13IBI3 loans
4e5elr# )ort.a.e pa#a0les
*%uit# in installment purc+ases Suret# lia0ilities
Intellectual properties 3uarant# lia0ilities
-t+ers 4u&.ment &e0ts
6oans from ot+er institutions
-t+ers
+otal !+p, +otal !+p,
$. Ne- Wr-4: De1/,r,0-3S8u&e3De1/,r,0-)& C4i/dre0 Be/5 #6 +e,r& ' A2e i0 De1/,r,0-)& Hu&e4/d
Reference 0ection Net 1orth At 2istorical Value
1
%Php&
B1 (otal /eal !roperties an& )otor 7e+icles
B281 add, (otal In,estments
B282 (otal -t+er !ersonal !roperties
B289 deduct, (otal 6ia0ilities
+otal !+p,
Acuisition costs of -eal Properties and .ehicles, and Investments and Other Personal Properties/ less total outstandin$ #alance of "ia#ilities

C. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS OF DECLARANT3S*OUSE3DECLARANT)S
CHILDREN BELOW #6 +EARS OF AGE LIVING IN THE HOUSEHOLD OF DECLARANT
(USE ADDITIONAL SHEET IF NECESSAR+%
Instru(tion: 'e(lare ea(- ite$ w-i(- generates gross annual re(eipts o" P-p 45#555 or $ore. Ite$s wit- less value $ay be
de(lared in lu$p su$ as 6Ot-ers7. 'owever, if %Others& amounts to more than Php (00,000, each item must #e listed
I have no business interests and financial connections to declare pertaining to me/my spouse/my children below 18 years of age living in
my household.
3eclarant4 0pouse4 or
Child %Put Na!e&
Na!e of ntity Address Nature of (usiness
+nterest/"inancial
Connection
3ate of
Acquisition/
Connection
D. DECLARANT)S RELATIVES IN THE GOVERNMENT (USE ADDITIONAL SHEET IF NECESSAR+%
Instruction, 0p to the 1
th
civil de$ree of relationship, either of consan$uinity or affinity, includin$ #ilas, inso and #alae
I dont know of any relatives in Government.
Na!e of Relati,e Relationship Position -ffice/Address
E. STATEMENT
I +ere0# certif# to t+e 0est of m# $no5le&.e an& information t+at t+ese are complete an& true statements of m# assets2 lia0ilities2
net 5ort+2 0usiness interests2 an& financial connections2 inclu&in. t+ose of m# spouse an& m# c+il&ren 0elo5 1: #ears of a.e li,in. in m#
+ouse+ol&2 an& t+e names of m# relati,es in t+e 3o,ernment2 as of 2 as re%uire& 0# an& in accor&ance
5it+ /epu0lic 1ct No8 ;<198 I further certify that no assets, lia#ilities, #usiness interests, financial connections, and relatives in the
2overnment other than those declared herein are known to me, my spouse, and my children #elow (3 years of a$e livin$ in my household!
I +ere0# aut+ori=e t+e -m0u&sman or +is &ul# aut+ori=e& representati,e to o0tain an& secure from all appropriate .o,ernment
a.encies2 inclu&in. t+e Bureau of Internal /e,enue2 suc+ &ocuments t+at ma# s+o5 suc+ assets2 lia0ilities2 net 5ort+2 0usiness interests2
an& financial connections2 inclu&in. t+ose of m# spouse an& m# c+il&ren 0elo5 1: #ears of a.e li,in. in m# +ouse+ol&2 co,erin. pre,ious
#ears2 inclu&in. t+e #ear I first assume& office in 3o,ernment8
I furt+er un&erta$e to pro&uce all supportin. &ocuments for eac+ of t+e entries +erein ma&e 5+en re%uire&8
Declarant>s Si.nature: Date (IN:
"ommunit# (a? "ert No: Issue& In: Issue& -n:
I0 1,&e ' ;i0- 'i/i02:
Spouse>s Si.nature: Date (IN:
"ommunit# (a? "ert No: Issue& In: Issue& -n:
S@BS"/IB*D 1ND SA-/N (- 0efore me on t+is &a# of 2 202
affiant(s) e?+i0itin. +is/+er/t+eir "ommunit# (a? "ertificate(s) as in&icate& a0o,e8

(!erson 1&ministerin. -at+)

F. GENERAL INSTRUCTIONS FOR BASELINE DECLARATION
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Baseline Declaration Form (5/19/2014)
1. Please write your responses in !! "PI#! letters using $%!& '!! P(% to avoid blotting.
). #he Baseline Declaration (BD)* which contains a comprehensive listing of your assets* liabilities* net worth*
business interests* and financial connections* must be submitted by new entrants within +, days after
assumption into office* and by incumbents on or before pril +,* ),,8. #his form must be accomplished
only once.
+. #he statement of a new entrant must contain comprehensive information as of his/her first day of
Government service. #he statement of an incumbent must contain his/her assets* liabilities and networth as of
-ecember +1* ),,..
/. #he BD must be accomplished in triplicate* of which two 0)1 copies must be submitted to the
dministration/Personnel -ivision/2nit of your agency.
3. 4or joint filing by husband and wife* make two 0)1 entries in 5ection for the %ame* Position* nnual
Gross 5alary* %ame of gency/$ffice* and $ffice ddress. Also, the co-declarant must sign the Statement
under Section E.
6. &ou may use additional forms or sheets if information e7ceeds the spaces provided.
.. Put 8%/9 for each entry that does not apply to you.
8. &ou must provide information for your spouse* if any* regardless of the status of marriage* e7cept only when
your marriage has been declared null and void: has been annulled: or a decree of legal separation has been
procured* with finality.
;. &ou must provide information for all your children below 18 years of age living in your household*
regardless of legitimacy or illegitimacy.
1,. #he fair market value of real property is that amount which a willing buyer and a willing seller can agree on
as the purchase price of the property. &ou may refer to historical data* such as sales transactions of real
properties* in the same vicinity.
11. #he assessed value of real property is that recorded in the ssessors $ffice* the local #reasurer* or the
5anggunian in the city or municipality where the real property is located.
1). %ote that you are not re<uired to attach any documents to vouch for or substantiate the information disclosed
at the time of submission. =owever* you must ensure that all information provided is supported by proper
and ade<uate documentation* and must be prepared to produce the same when re<uired in the future.
1+. >oreover* the 5!% is made under oath. 4alsification of information or failure to file or report information
may sub?ect you to disciplinary action. -eliberate and willful falsification of information may also sub?ect
you to criminal prosecution.
1/. Penalties under @ 6.1+ may be any of the followingA
Imprisonment B five years
4ine B PhP 3* ,,,
-ismissal from the service
13. 4or further guidance* 5!% >anualA Guide to 4illing $ut &our 5!% 4orm is available from the
"ivil 5ervice "ommission and your =uman @esource -ivision. &ou may also contact the Integrated
@ecords >anagement $ffice 0I@>$1 at ;+1C.;81* ;+1C.;8.* and ;31C/6)8 for assistance in
completing the 5!%.
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