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: DOMULOT MARIA JOY G. POSITION: TEACHER I
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEPARTMENT OF EDUCATION
OFFICE ADDRESS: LINGAYEN , PANGASINAN
ADDRESS: # 70 ABONAGAN , MALASIQUI ,
PANGASINAN
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 ACQUISITION
VALUE MARKET VALUE
EXACT
(e.g., residential,
ACQUISITION COST
(e.g. lot, house and lot, LOCATION
commercial, industrial, (As found in the Tax Declaration of Real
condominium, and
Property)
YEAR MODE
agricultural and mixed
improvements)
used)
Subtotal: -
b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT
GADGETS 2018 29,000.00
Subtotal: 29,000.00
TOTAL ASSETS (a+b): 29,000.00
2. LIABILITIES*
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
TOTAL LIABILITIES: -
* Additional sheet/s may be used, if necessary. NET WORTH: Total Assets less Total Liabilities = 29,000.00
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
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
LOURDES MACARAEG COUSIN TEACHER DepED
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: JANUARY 21, 2019
(Signature of Declarant) (Signature of Co-Declarant/Spouse)
Government Issued ID: PRC ID Government Issued ID:
ID No: 1585514 ID No.:
Date Issued: 19/12/2017 Date Issued:
SUBSCRIBED AND SWORN to before me this _______ day of ____________________ , affi ant exhibiting to me the above-stated government issued
identification card.
(Person Administering Oath)
