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Revised as of January 2015

Per CSC Resolution No. 1500088
Promulgated on January 23, 2015

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of _____APRIL 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  Not Applicable

DECLARANT SUMAGDON, JR. ANTOLEN N. POSITION: TEACHER II
:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEp.ED/STO.NIÑO NATIONAL
HIGH SCHOOL
ADDRESS: BRGY. PALALE STA. MARGARITA W. SAMAR OFFICE ADDRESS: STO. NIÑO SAMAR

SPOUSE: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:
OFFICE ADDRESS:

UNMARRIED CHILDREN BELOW EIGHTEEN (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 children below eighteen (18)
years of age living in declarant’s household)

1. ASSETS
a. Real Properties*

DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION
(e.g. lot, house and (e.g. residential, LOCATION VALUE MARKET VALUE COST
lot, condominium commercial, industrial,
(As found in the Tax Declaration of
and improvements) agricultural and mixed YEAR MODE
Real Property)
use)

Subtotal:
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION
COST/AMOUNT

Laptop and Gadgets 2014 Þ 30,000.00

Subtotal : Þ 30,000.00

TOTAL ASSETS (a+b): Þ 30,000.00
Page 1 of ___

* Additional sheet/s may be used. Page 2 of ___ . if necessary.

: 490-918-528-000 ID No. including the Bureau of Internal Revenue such documents that may show my assets. NAME 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. net worth. DIMARANAN EMPLOYER CITY.00 * Additional sheet/s may be used. including those of my spouse and unmarried children below eighteen (18) years of age living in my household. if necessary. Include also Bilas. LIABILITIES* NATURE NAME OF CREDITORS OUTSTANDING BALANCE TOTAL LIABILITIES: NET WORTH : Total Assets less Total Liabilities = Þ 30.ADMINISTRATIVE. net worth. Date: 04/29/2017 (Signature of Declarant) (Signature of Co-Declarant/Spouse) Government Issued ID: BIR Government Issued ID: ID No. business interests and financial connections. liabilities. I hereby authorize the Ombudsman or his/her duly authorized representative to obtain and secure from all appropriate government agencies. business interests and financial connections. the above- enumerated are names of my relatives in the government within the fourth civil degree of consanguinity or affinity. 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. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (of Declarant /Declarant’s 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. liabilities.000. CALBAYOG CITY GOVERNMENT ASSIT I hereby certify that these are true and correct statements of my assets.: Date Issued: OCTOBER 06. and that to the best of my knowledge. Balae and Inso)  I/We do not know of any relative/s in the government service) NAME OF RELATIVE RELATIONSHIP POSITION NAME OF AGENCY/OFFICE AND ADDRESS DEMETRIO C.2.2015 Date Issued: Page 3 of ___ .

_______________________________________ (Person Administering Oath) Page 4 of ___ . affiant exhibiting to me the above-stated government issued identification card. SUBSCRIBED AND SWORN to before me this day of .