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SWORN STATEMENT OF ASSETS, LIABILITIES, AND NET WORTH,

DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS,


AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE
As of December 31, _2010
(Required by Republic Act No. 6713)

Name: UY THERESE LEAH M._________ Position: TEACHER 1_____________


(Surname) (First) (MI.) Income: ___P 16 188.66______________
Address: ZONE 9B BLOCK 5, FATIMA, GENERAL SANTOS CITY, 9500, PHILIPPINES
Office/School: NASA ELEMENTARY SCHOOL, Fatima, ___DEPARTMENT OF EDUCATION, General Santos City
Spouse Name: UY BIRTHRANT C. Position: __N/A ___________________
(Surname) (First) (MI.) Office: ____N/A ____________________
Address: __N/A ____________________
Unmarried Children below 18 years of age:

Name Date of Birth


1. THERESE LYLE M. UY APRIL 15, 2000
2. THERESE AMLIBETH M. UY JANUARY 13, 1999
3. N/A N/A
4. N/A N/A
5. N/A N/A

A. ASSETS, LIABILITIES AND NET WORTH

I. ASSETS
a. Real Properties
Acquisition Cost
Year Mode of Assessed Current Fair
Kind Location
Acquired Acquisition Value Market Value Land,
Improvements
Building, etc.
NA NA NA NA NA NA NA NA
NA NA NA NA NA NA NA NA
NA NA NA NA NA NA NA NA
NA NA NA NA NA NA NA NA
NA NA NA NA NA NA NA NA
TOTAL (1a) P

b. Personal and Other Properties


Kind Year Acquired Acquisition Cost
Mitsubishi Lancer-TCA 313 2009 70 000.00

TOTAL (1b) P 70 000.00


TOTAL ASSETS (1a + 1b) TOTAL P 70 000.00

II. LIABILITIES (Loans, Mortgages, etc.)


Nature Amount
BANK LOAN- NETWORK BANK 75 000.00
PAG-IBIG SALARY LOAN 5 000.00

TOTAL (II) P 80 000.00

NET WORTH [Total Assets (1a + 1b) = P 70 000.00


TOTAL P -10 000.00
Less: Total Liabilities (II) = P 80 000.00

(NOTE: Please use additional forms / sheets if necessary. Also, please reproduce this form back to back.)
B. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

Do you have any business interests and other financial connections including those of your spouse and unmarried children
below 18 years of age living with you in your household?
Yes √ No If yes, give particulars:

Nature of Business Date of


Name of Firm/
Name Address Interest and/or Financial Acquisition
Company
Connections or Connection
NA NA NA NA NA
NA NA NA NA NA
NA NA NA NA NA
NA NA NA NA NA

C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE

To the best of your knowledge, are you related within the fourth degree of consanguinity or of affinity to anyone working in
the government? √ Yes __ No If yes, give particulars:

Name Position Relationship Name/Address of Office


TERESITA M. SIEBERS ES-1 MOTHER DEPED OFFICE, GEN. SANTOS CITY

I hereby certify to the best of my knowledge and information that these are true statements of my assets, liabilities, net
worth, business interests and financial connections, including those of my spouse and unmarried children below 18
years of age and names of my relatives in the government as of December 31, 2009, as required by and in accordance with
Republic Act 6713.

I hereby authorized the Ombudsman or his 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 past years to include the year I first assumed office in government.

Date: APRIL 6, 2010

Signature of Spouse Signature of Employee

TIN 947 – 788 - 678 TIN 921 – 343 – 133


Com. Tax Cert. No. 19120480 Com. Tax Cert. No. CCI2008 19065604
Issued at FATIMA, GENERAL SANTOS CITY Issued at FATIMA, GENERAL SANTOS CITY
Issued on MARCH 16, 2010 Issued on JANUARY 12, 2010

SUBSCRIBED AND SWORN TO before me this ________day of ________________, 20 ____, affiant exhibiting
his/her Community Tax Certificate as indicated above.

Person Administering Oath

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