QCG-CAO-QP/SOI-E01-v01 Last revised 11/25/2019

SWORN STATEMENT OF THE TRUE CURRENT AND FAIR MARKET VALUE OF REAL PROPERTIES

(Taxable/Exempt)
(Required under Section 202 of Republic Act 7160)

I, _________________________________________________________, of legal age, _________________________ and with postal address

at ________________________________________________________, after having been duly sworn to in accordance with law, depose and say:

1. That I am the _____________________________________________________ of the following real properties (lands, buildings, machineries, and other
improvements) located in the City/Municipality of ________________________________, Metro Manila, owned by _________________________________________
__________________________________________________________________of which the description and true current and fair market value/s are as follows:

A. LANDS (Residential, Commercial, Industrial, Agricultural, Special)

Existing Tax Cadastral/ Area Classification Location of Property True Current &
Dec. No. Lot No. Block No. Pls.No. TITLE No. (Has./Sq.m.) (Res./Com./Ind.etc) (St./Dist./Barangay) Fair Market Value
P
P
P
P
P

B. BUILDING AND OTHER STRUCTURES

Existing Tax Floor Area No. Owner of Lot Where Bldg is Location of Property True Current &
Dec. No. in sq.m. Storey General Description Year Completed/Occupied Actual Use Constructed (St./Dist./Barangay) Fair Market Value
P
P
P
P
P
C. MACHINERIES
Existing Tax DATE VALUE OF TRUE CURRENT & FAIR
DEPRECIATION
Dec. No. DESCRIPTION ACQUIRED ORIGINAL ACQUISITION
COMMENCED OPERATION COST OF
COST
INSTALLATION ON SITE PLACE OF INSTALLATION MARKET VALUE
P P P P
P P P P
P P P P
P P P P

C. OTHER IMPROVEMENTS (Perennial Trees/Plants)

Existing Tax NO OF TREES/HA. ANNUAL PRODUCT NO. OF TREES/HA. & TRUE CURRENT AND FAIR MARKET VALUE
Dec. No. KINDS OF TREES/PLANTS PRODUCTIVE PER TREE/HA. AGES NON PRODUCTIVE PRODUCTIVE NON-PRODUCTIVE
P P
P P
P P
P P
2. That I am executing this sworn statement in compliance with Section 202 of RA 7160 (Local Gov't Code of 1991)

IN WITNESS WHEREOF, I have hereunto affixed my signature this __________ day of ___________________________________ 20 _____ at _______________________,
if thumbmarked, require signatures of two (2) witnesses:
____________________________________
(Signature of Affiant)
____________________________________ ____________________________________ TIN __________________
Witness Witness

SUBSCRIBED AND SWORN to before me this ________ of ______________, 20 ___, affiant exhibiting his/her Residence Certificate No. A-__________________
issued on ___________________________________ at _______________________________________________________, Philippines.

____________________________________
Signature of Administering Officer
Note:
TIN __________________
(1) Include in this sworn statement only real property owned or administered by the affiant in one's municipality or city.
(2) Prepare three (3) copies and after having been subscribed to by the affiant, submit the same to the City or Municipal Assessor of the city or municipality where the property is located; the original and
duplicate to be retained by the receiving office and the triplicate to be returned to the affiant after receipt thereof has been duly acknowledged.
(3) Write "NEW" under column "Existing Tax Dec. No." for property not previously declared and attach corresponding proo f of ownership and technical description and boundaries thereof.
(4) Original Acquisition Cost of Machinery includes such cost of freight and insurance charges, brokerage arrastre and handling, custom duties and taxes; costa of inland transportation and handling.
(5) Write additional information in another sheet, if necessary.