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 x Not Applicable
DECLARANT: TEE ARIEL M. POSITION: PAA III
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: Cong. Milagrosa T. Tan
ADDRESS: OFFICE ADDRESS: SW 419 Batasan Hills, Quezon City
494 San Francisco St.,
Palompon, Leyte
SPOUSE: N/A POSITION: N/A
(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
N/A
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
use) Real Property)
N/A N/A
Subtotal:
b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION
COST/AMOUNT
Cash 52,000.00
Jewelries 50,000.00
Gadgets 80,000.00
Subtotal : 182,000.00
182,000.00
TOTAL ASSETS (a+b):
* Additional sheet/s may be used, if necessary.
Page 1 of ___
2. LIABILITIES*
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
N/A N/A
TOTAL LIABILITIES:
NET WORTH : Total Assets less Total Liabilities = 182,000.00
* 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
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
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: ___April 25, 2018______________________
(Signature of Declarant) (Signature of Co-Declarant/Spouse)
Government Issued ID: Government Issued ID:
ID No.: 17003745 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)
