Form Monitoring Kinerja Admen Bulan Agustus 2017Deskripsi lengkap
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of January 2017 (Required by R.A. 6713)
Note: Husband and wife who are both public officials and employees may file the required statements jointly or separately.
Joint Filing
Separate Filing
DECLARANT:
Not Applicable
(Family Name)
(First Name)
(.!.)
POSITION: AGENCY/OFFICE: OFFICE ADDRESS:
(Family Name)
(First Name)
(.!.)
POSITION: AGENCY/OFFICE: OFFICE ADDRESS:
ADDRESS:
SPOUSE:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIING IN DECLARANT!S HOUSEHOLD NAME
DATE OF BIRTH
AGE
ASSETS, LIABIL LIA BILITI ITIES ES AND NETWOR NET WORTH TH (ncluding those of the spouse and unmarried children below eighteen (!"# years of age li$ing in declarant%s household# 1" ASSETS #"
Re#$ P%o&e%t'e
DESCRIPTION
*IND
E+ACT
ASSESSED
CURRENT FAIR
(e.". lot# $ouse and lot# %ondominium and im&ro'ements)
(e.". residential# %ommer%ial# industrial# a"ri%ultural and mied use)
LOCATION
ALUE
MAR*ET ALUE
(As found in t$e a *e%laration of Real +ro&erty)
TOTAL LIABILITIES: NET WORTH : Tot#$ Aet $e Tot#$ L'#.'$'t'e 2 Additional sheet&s may be used' if necessary.
Page 1 of 2
OUTSTANDING BALANCE
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (of eclarant &eclarant%s spouse& )nmarried *hildren +elow ,ighteen (!"# years of Age -i$ing in eclarant%s Household#
&/e do not ha$e any business interest or financial connection . NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
NATURE OF BUSINESS INTEREST 3/OR FINANCIAL CONNECTION
DATE OF ACUISITION OF INTEREST OR CONNECTION
RELATIES IN THE GOERNMENT SERICE (/ithin the Fourth egree of * onsanguinity or Affinity. nclude also +ilas' + alae and nso#
I/We do not know of any relative/s in the government service) NAME OF RELATIE
RELATIONSHIP
POSITION
NAME OF AGENCY/OFFICE AND ADDRESS
! $ereby %ertify t$at t$ese are true and %orre%t statements of my assets# liabilities# net ,ort$# business interests and finan%ial %onne%tions# in%ludin" t$ose of my s&ouse and unmarried %$ildren belo, ei"$teen (1-) years of a"e li'in" in my $ouse$old# and t$at to t$e best of my no,led"e# t$e abo'e/ enumerated are names of my relati'es in t$e "o'ernment ,it$in t$e fourt$ %i'il de"ree of %onsan"uinity or affinity.
! $ereby aut$orie t$e mbudsman or $is$er duly aut$oried re&resentati'e to obtain and se%ure from all a&&ro&riate "o'ernment a"en%ies# in%ludin" t$e ureau of !nternal Re'enue su%$ do%uments t$at may s$o, my assets# liabilities# net ,ort$# business interests and finan%ial %onne%tions# to in%lude t$ose of my s&ouse and unmarried %$ildren belo, 1- years of a"e li'in" ,it$ me in my $ouse$old %o'erin" &re'ious years to in%lude t$e year ! first assumed offi%e in "o'ernment. *ate4
555555555555555555555555555555
(Signature of eclarant#
(Signature of *o0eclarant&Spouse#
o'ernment !ssued !*4 !* No.4 *ate !ssued4
o'ernment !ssued !*4 !* No.4 *ate !ssued4
SUBSCRIBED AND SWORN to before me t$is "o'ernment issued identifi%ation %ard.
