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Revised as of January 2015Per CSC Resolution No. 1500088Promulgated on January 23, 2015 SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH s of !!!!!!!!!!!!!!!!!!!!!!!!!! Re#uired $y R.. %&13' Note: Husband and wife who are both public officials and employees may file the required statements jointly or separately. Joint Filing Separate Filing Not Applicable DECLARANT POSITION: (amily Name' (irst Name' ).*.' AGENCY/OFFICE:ADDRESS:OFFICE ADDRESS:SPOUSE:POSITION: (amily Name' (irst Name' ).*.' AGENCY/OFFICE:OFFICE ADDRESS: ASSETS, LIABILITIES AND NETWORTH !ncluding those of the spouse and unmarried children below eighteen #$ years of age li%ing in declarant&s household$ 1. ASSETSa.Real Properties* DESCRIPTION e.g. lot, +ouse andlot, ondominiumand im-rovements' IND e.g. residential,ommerial, industrial,agriultural and mieduse' E!ACT LOCATIONASSESSED ALUECURRENT FAIRMARET ALUEAC#UISITIONAC#UISITIONCOST s found in t+e /a elaration of Real Pro-erty' YEARMODE S$%total:%. Pe&'o(al Properties* DESCRIPTIONYEAR AC#UIREDAC#UISITIONCOST/AMOUNT S$%total :TOTAL ASSETS )a*%+: Additional sheet's may be used( if necessary. Page 1 of ___ UNMARRIED CHILDREN BELOW EIGHTEEN )1-+ YEARS OF AGE LI ING IN DECLARANTS HOUSEHOLD NAMEDATE OF BIRTHAGE .LIABILITIES NATURENAME OF CREDITORSOUTSTANDING BALANCE TOTAL LIABILITIES:NET WORTH : Total A''et' le'' Total L0a%0l0t0e' Additional sheet's may be used( if necessary. 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/BUSINESSENTERPRISEBUSINESS ADDRESSNATURE OF BUSINESSINTEREST 2/OR FINANCIAL CONNECTIONDATE OF AC#UISITION OFINTEREST OR CONNECTION RELATI ES IN THE GO ERNMENT SER ICE /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 RELATI ERELATIONSHIPPOSITIONNAME OF AGENCY/OFFICE AND ADDRESS * +ere$y ertify t+at t+ese are true and orret statements of my assets, lia$ilities, net ort+,$usiness interests and finanial onnetions, inluding t+ose of my s-ouse and unmarried +ildren $eloeig+teen 18' years of age living in my +ouse+old, and t+at to t+e $est of my noledge, t+e a$oveenumerated are names of my relatives in t+e government it+in t+e fourt+ ivil degree of onsanguinity oraffinity. * +ere$y aut+ori4e t+e m$udsman or +is6+er duly aut+ori4ed re-resentative to o$tain andseure from all a--ro-riate government agenies, inluding t+e 7ureau of *nternal Revenue su+douments t+at may s+o my assets, lia$ilities, net ort+, $usiness interests and finanial onnetions,to inlude t+ose of my s-ouse and unmarried +ildren $elo 18 years of age living it+ me in my +ouse+old overing -revious years to inlude t+e year * first assumed offie in government. 0ate8 !!!!!!!!!!!!!!!!!!!!!!!!!!!!!! Signature of )eclarant$Signature of +o0)eclarant'Spouse$ 9overnment *ssued * 9overnment *ssued ** No.* No.ate *ssued ate *ssued SUBSCRIBED AND SWORN to $efore me t+is 31 st day of eem$er, affiant e+i$iting to me t+e a$ovestated government issued identifiation ard. !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! 1erson Administering 2ath$ Page 2 of ___
