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

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*

ASSESSED CURRENT FAIR

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

Subtotal: -
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT

Subtotal: -
TOTAL ASSETS (a+b): -
2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

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 TOTAL LIABILITIES: -
* Additional sheet/s may be used, if necessary. NET WORTH: Total Assets less Total Liabilities = -

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 INTEREST DATE OF ACQUISITION OF

ENTERPRISE & / OR FINANCIAL INTEREST OR CONNECTION
CONNECTION

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

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: Government Issued ID:

ID No: 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.

(Person Administering Oath)

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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 December 31, 2019
(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: AGOT, MAR V. POSITION: MASTER TEACHER II
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DepEd- Cagayan de Oro City
OFFICE ADDRESS: Father William Mastersons Aveneue,
ADDRESS: STA. CRUZ I, LAPASAN, CAGAYAN DE ORO CITY, Upper Balulang, Cagayan de Oro City
MISAMIS ORIENTAL

SPOUSE: AGOT, MARIEN COLINE J. POSITION: Teacher I

(Family Name ) (First Name) (M.I.) AGENCY/OFFICE: Deped-Malaybalay Bukidnon
OFFICE ADDRESS: Sumpong, Malaybalay, Bukidnon

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT'S HOUSEHOLD
NAME DATE OF BIRTH AGE
NA

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*

ASSESSED CURRENT FAIR

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

Salimpono,
Panaon,
House and Lot Residential Misamis. Occ. 2017 280,000.00

Subtotal: 280,000.00
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT

Personal Belongings 2018-2019 25,000.00

Furniture and Appliances 2017 20,000.00
Short & Long Term Investments (GSIS, PAG-IBIG, BPI-Philam, Fortune Life, St. Peter Life Plans & Golden Haven) 2016 to present 180,000.00
Cash in Bank 2019 60,000.00
Subtotal: 285,000.00
TOTAL ASSETS (a+b): 565,000.00
2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

Bank Loan One Network Bank 452,000.00

TOTAL LIABILITIES: 452,000.00

NET WORTH: Total Assets less Total Liabilities = 113,000.00
* Additional sheet/s may be used, if necessary.

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

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 (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 INTEREST DATE OF ACQUISITION OF

ENTERPRISE & / 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 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: 29-Jan-20

(Signature of Declarant) (Signature of Co-Declarant/Spouse)

Government Issued ID: PRC ID Government Issued ID: 1301348

ID No: 0981187 ID No.: PRC ID
Date Issued: 10/26/2019 Date Issued: 5/12/2017

SUBSCRIBED AND SWORN to before me this _______ day of ____________________ , affiant exhibiting to me the above-stated government issued
identification card.

(Person Administering Oath)

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