ABCDEFGHIJKLMNOPQRSTUVWXYZ
1
STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
2
AND DISCLOSURE OF BUSINESS INTERESTS, FINANCIAL CONNECTIONS
3
AND RELATIVE/S IN THE GOVERNMENT SERVICE
4
As of December 31, 2018
5
(Required by R.A. Nos. 3019 and 6713)
6
7
(Note:) Husband and wife who are both public officals or employees may
8
file the required statements jointly or separately.)
9
10
Jointly filed
Separately filrd
11
12
Name: Position
13
(Surname)(First Name) (M.I.) Office
14
Address: Office
15
Address
16
17
I am married I am not married
18
19
Spouse Position
20
(Surname)(First Name) (M.I.) Office
21
Office
22
Address
23
24
Unmarried children below 18 years of age living in his/her household: (Use additional sheet/s if necessary)
25
Name Date of Birth
26
1.
27
2.
28
3.
29
30
I have no children below years of age living in my household .
31
32
I. ASSETS (including that of declarant's spuse and unmarried children below18 years of age living in his/her household
33
34
A. REAL PROPERTY/IES. (use additional sheet/s, if necessary.)
35
KINDNATURE OF LOCATION ACQUISITION ASSESSED ACQUISITION COST
36
PROPERTYFAIR
37
MARKET
38
MODEYEARVALUE VALUE Land, Bldg, Improvement/s
39
others
40
41
42
43
44
TOTAL
45
46
B. PERSONAL PROPERTY/IES AND OTHER ASSETS (use additional sheet/s, if necessary)
47
PROPERTIES/ASSETS ACQUISITION ACQUISITION COST*
48
MODEYEAR
49
Tangible
50
51
52
53
Intangible
54
55
56
TOTAL 0
57
58
*For computation purposes, use acquisition cost. Properties of unmarried children below 18 years of age living in
59
his/her household shall be excluded as well as the paraphernal/exclusive properties of spouse, in case of separate
60
filing.
61
TOTAL ASSETS (A+B) =
0
62
63
II. LIABILITIES (including that of declarant’s spouse and unmarried children below 18 years of age living in his/her
64
 household)
65
NATURE NAME OF CREDITOR/S *OUTSTANDING BALANCE
66
67
68
69
70
(use additional sheet/s if necessary)
TOTAL 0
71
72
*In the computation of outstanding balance, properties of unmarried children below 18 years of age living in his/her
73
household shall be excluded as well as the paraphernal/exclusive properties of spouse, in case of separate filing.
74
75
III. NET WORTH (TOTAL ASSETS (I) LESS TOTAL LIABILITIES (II) = NET WORTH (III)
76
77
TOTAL NET WORTH:
0
78
79
AMOUNT AND SOURCES OF INCOME
80
(ALL amounts received from ALL sources for the preceeding calendar year)
81
NATURE SOURCESAMOUNT
82
(salary/income, business, etc.)
83
84
85
86
(use additional sheet/s if necessary)
TOTAL 0
87
88
AMOUNT OF PERSONAL AND FAMILY EXPENSES
89
(for the preceding calendar year)
90
PERSONAL EXPENSES ESTIMATED AMOUNT FAMILY EXPENSES ESTIMATED AMOUNT
91
92
93
94
95
TOTAL 0TOTAL -
96
(use additional sheet/s if necessary)
97
AMOUNT OF INCOME TAXES PAID
98
(for the preceding calendar year)
99
NATURE AMOUNT
100
Compensation