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 December 31, 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: BAUTISTA KHERLYN M. POSITION: TEACHER II
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEPARTMENT OF EDUCATION
ADDRESS: 12 BANTUGAN POZORRUBIO, PANGASINAN OFFICE ADDRESS: PANGASINAN DIVISION II
BINALONAN
SPOUSE: BAUTISTA MARVIN M. POSITION: PHARMACY ASSISTANT
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: ST. JOSEPH DRUGSTORE
OFFICE ADDRESS: POZORRUBIO, PANGASINAN
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NAME DATE OF BIRTH AGE
KHERVIN MATTHEW M. BAUTISTA OCTOBER 25, 2015 3
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
Real Property)
YEAR MODE
use)
N/A N/A N/A N/A N/A N/A N/A N/A
Subtotal:
b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION
COST/AMOUNT
Watch 2019 500.00
Mobile Phone 2017 10,000.00
Necklace 2014 10,000.00
Ring 2014 6,000.00
Subtotal : 26, 500.00
TOTAL ASSETS (a+b): 26, 500.00
Page 1 of ___
* Additional sheet/s may be used, if necessary.
Page 2 of ___
2. LIABILITIES*
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
N/A N/A N/A
TOTAL LIABILITIES: 0
NET WORTH : Total Assets less Total Liabilities = 26, 500.00
* Additional sheet/s may be used, if necessary.
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.
NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF
ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION
N/A N/A N/A N/A
RELATIVES IN THE GOVERNMENT SERVICE
(Within the Fourth Degree of Consanguinity or Affinity. Include also Bilas, 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
N/A N/A N/A
I hereby certify that these are true and correct statements of my assets, liabilities, net worth,
business interests and financial connections, including those of my spouse and unmarried children below
eighteen (18) years of age living in my household, and that to the best of my knowledge, the above-
enumerated are names of my relatives in the government within the fourth civil degree of consanguinity or
affinity.
I hereby authorize the Ombudsman or his/her duly authorized representative to obtain and
secure from all appropriate government agencies, including the Bureau of Internal Revenue such
documents that may show my assets, liabilities, net worth, business interests and financial connections,
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.
Date: ______________________________
(Signature of Declarant) (Signature of Co-Declarant/Spouse)
Government Issued ID: PAG-IBIG Government Issued ID:
ID No.: 9122-6820-1508 ID No.:
Date Issued: Date Issued:
SUBSCRIBED AND SWORN to before me this day of , affiant exhibiting to me the above-stated
government issued identification card.
MA. LUISA P. ALEGADO, PRINCIPAL III
(Person Administering Oath)
Page 3 of ___
