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.
q Joint Filing q Separate Filing q Not Applicable
DECLARANT: CRUZ JUANA D POSITION: TEACHER III
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEPED EL SALVADOR CITY
ADDRESS: ZONE 3, POBLACION, EL SALVADOR CITY OFFICE ADDRESS: ZONE 3, POBLACION
MISAMIS ORIENTAL 9017 EL SALVADOR CITY, 9017
SPOUSE: N/A POSITION: N/A
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: N/A
OFFICE ADDRESS: N/A
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NAME DATE OF BIRTH
AGE
N/A N/A 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 ACQUISITION
ASSESSED CURRENT FAIR
VALUE MARKET VALUE
ACQUISITION
(e.g. residential, LOCATION
(e.g. lot, house and commercial, COST
lot, condominium and industrial,
(As found in the Tax Declaration of Real
YEAR MODE
improvements) agricultural and
mixed use) Property)
NONE N/A N/A N/A N/A N/A N/A N/A
Subtotal: -
b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT
GADGETS (CELLPHONE, IPAD & LAPTOP) VARIOUS YEARS 50,000.00
CASH (IN BANK & ON HAND) VARIOUS YEARS 60,000.00
INSURANCE POLICIES VARIOUS YEARS 15,000.00
Subtotal : 125,000.00
TOTAL ASSETS (a+b): 125,000.00
2. LIABILITIES*
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
PERSONAL LOAN MARIA DELA CRUZ 78,000.00
TOTAL LIABILITIES: 78,000.00
NET WORTH : Total Assets less Total Liabilities = 47,000.00
* 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)
q I/We do not have any business interest or financial connection.
NAME OF ENTITY/BUSINESS NATURE OF BUSINESS INTEREST &/OR DATE OF ACQUISITION OF
BUSINESS ADDRESS
ENTERPRISE FINANCIAL CONNECTION INTEREST OR CONNECTION
NONE 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)
q I/We do not know of any relative/s in the government service)
NAME OF RELATIVE RELATIONSHIP POSITION NAME OF AGENCY/OFFICE AND ADDRESS
MAJA D. SALVADOR AUNTIE AO-V DEPARTMENT OF EDUCATION- CEBU CITY DIVISION
ERIC L. CRUZ COUSIN NURSE-II UNIVERSTY OF SCIENCE AND TECHNOLOGY OF THE PHILIPPINES
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:
N/A
(Signature of Declarant) (Signature of Co-Declarant/Spouse)
Government Issued ID: PASSPORT Government Issued ID: N/A
ID No.: EB1234567 ID No.: N/A
Date Issued: August 17, 2017 Date Issued: N/A
SUBSCRIBED AND SWORN to before me this _______ day of _________________________ , affiant exhibiting to me
the above-stated government issued identification card.
(Person Administering Oath)
