5 Letter To Request Face Tod Face

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, 2018
(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: Javier Arlene P. POSITION: Admin Aide 3

(Family Name) (First Name) (M.I.) AGENCY/OFFICE: Treasury Office
ADDRESS: Brgy. Sampaloc, Pagsanjan, Laguna OFFICE ADDRESS: J.P. Rizal Street Pob. Uno,
Pagsanjan, Laguna
SPOUSE: Javier Crisanto Y. 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
Jesus Leonard P. Javier February 25, 2006 13 years old
Alyannah Mariz P. Javier February 20, 2011 8 years old
N/A N/A N/A
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 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 N/A N/A N/A N/A N/A N/A
Subtotal: N/A
b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT
Cellphone 2017-2018 35,000

Jewelries 2016-2018 20,000
Cash on hand/Bank 2018 90,000
Subtotal : 145,000
145,000
TOTAL ASSETS (a+b):
* Additional sheet/s may be used, if necessary.
Page 1 of ___
2. LIABILITIES*
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
Cash Loan GSIS 10,000

N/A N/A N/A
N/A N/A N/A
N/A N/A N/A
TOTAL LIABILITIES: 10,000
NET WORTH : Total Assets less Total Liabilities = 135,000
* 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
Coviertos Food Services Brgy. Cabanbanan, Food Service Provider December 2018
Pagsanjan, Laguna
N/A N/A N/A N/A
N/A N/A N/A N/A
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
Girlie Maita Javier Ejercito Sister-in-law LCE LGU-Pagsanjan
John Paul Ejercito Nephew-in-law Councilor LGU-Pagsanjan
N/A N/A N/A N/A
N/A N/A N/A N/A
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: ______________________________
(Signature of Declarant) (Signature of Co-Declarant/Spouse)
Government Issued ID: Municipal ID Government Issued ID:

ID No.: GME-192-C ID No.:
Date Issued: August 2, 2016 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)
Page 2 of ___

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Revised as of January 2015

Per CSC Resolution No. 1500088

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

DECLARANT: Javier Arlene P. POSITION: Admin Aide 3

SPOUSE: Javier Crisanto Y. POSITION:

ASSETS, LIABILITIES AND NETWORTH

DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

N/A N/A N/A N/A N/A N/A N/A N/A

DESCRIPTION YEAR ACQUIRED ACQUISITION

Cellphone 2017-2018 35,000

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

Cash Loan GSIS 10,000

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

 I/We do not have any business interest or financial connection .

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF

RELATIVES IN THE GOVERNMENT SERVICE

 I/We do not know of any relative/s in the government service)

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

Government Issued ID: Municipal ID Government Issued ID:

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