Forms 20 Saln

SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS AND IDENTIFICATION OF RELATIVES
IN THE GOVERNMENT SERVICE As of December 31,2011 (Required by R.A. 6713) REVILLA SURNAME ADDRESS : NATALIA TEQUIN FIRST NAME MIDDLE NAME BLOCK 25 LOT 20 ROSALINA I, PUAN, D.C. L.
MIDDLE NAME
POSITION/INCOME : OFFICE : OFFICE ADDRESS : POSITION :
ADMIN. OFFICER IV HRDS, DENR- REGION XI LANANG, DAVAO CITY
SPOUSE'S NAME : REVILLA ( DECEASED) ROBERTO

SURNAME FIRST NAME
UNMARRIED CHILDREN BELOW 18 YEARS OF AGE : NAME N/A __________________________________________ A. ASSETS, LIABILITIES AND NETWORTH 1. ASSETS A. Real Properties
NATURE OF YEAR M ODE OF ACQUI SI TI ON PROPERTY ASSESSED VAL UE, P CURRENT FAI R M ARK ET VAL UE, P ACQUI SI TI ON COST, P L AND, BUI L DI NG, ETC. I M PROVEM ENTS
DATE OF BIRTH N/A ____________________________________________
KIND
LOCATION
ACQUI RED
(paraphernal, conj ugal or community) -
Farm LotAgriculture ( 1 & 1/4 has.) Farm LotAgriculture ( 1 has.) Residential - House & Lot (100 sq. m)
Manikling, San Isidro, Davao Oriental Manikling, San Isidro, Davao Oriental
B lk 25 L o t 20 Ro salin a I, B ag o Gallera, Talo m o Dst. Pu an , D.C.
1985 1988 2009 1994
Purchased
P 100,0000.
P 500,000.00
700,000.00
Purchased
P 120,0000.
P 520,000.00
720,000.00
Purchased Purchased
P120,000.00
P300,000.00
P300,000.00
150,000.00
Residential Lot- (740 Manikling, San Isidro, sq. m.) Davao Oriental
P 25,990.00
P50,000.00 Total P
P50,000.00 1,920,000.00 ACQUISITION COST, P P100,000.00 75,000.00
B. Personal and Other Properties KIND/S Jewelries Furniture &Fixture YEAR ACQUIRED 1978 & some last year 1978 up to present
Total P 2. LIABILITIES (Loans, Mortgages, etc) NATURE Pag-ibig Multipurpose Loan Consolidated Loan Agriculture Loan Pawnshop Salary Loan NAME OF CREDITORS Pag-Ibig GSIS Individual Person Pawnshop Store SSS
175,000.00 AMOUNT, P P 52,796.68 242,670.00 60,000.00 20,000.00 5,000.00
Total P NETWORTH (Total Assets 1A & 1B Less Liabilities (2))
380,466.68 P 1,714,533.32
B. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS Do you have any business interest 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 BUSI NESS,
NAME NONE
NAME OF FIRM/ COMPANY
ADDRESS
I NTEREST AND/OR FI NANCI AL CONNECTI ON
DATE OF ACQUISITION/ CONNECTION
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 POSITION Executive assistant Cartographer Scaler If YES, give particulars : RELATIONSHIP Sister Sister Brother NAME/ADDRESS OF OFFICE
C/O DENR-RXI, Lanang, Davao City C/o DENR- RXI,CENRO West, Bangkal, Davao City C/o DENR- RXI, CENRO West, Bangkal, Davao City
NAME Nora T. Alicante Nilda T. Pasay Felixberto V. Tequin
I hereby certify to the best of my knowledge and information that these are true statements of my assets, liabilities, networth, 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 authorize the Ombudsman or his authorized representatives to obtain and secure from all appropriate government agencies including the Bureau of Internal Revenue, such documentsthat may show my assets, liabilities, networth, business interest and financial connection, to include those of my spouse and unmarried children below 18 years of age living with me in household covering previous years to include the year I first assumed office in the government. DATE: March 29, 2012 Signature of Spouse TIN: Comm. Cert. No. : Issued at : Issued on : TIN: Comm. Cert. No. : Issued at : Issued on : Signature 131-361-046 CC 12011 06052 981 Davao City January 11, 2012
SUBSCRIBED AND SWORN TO before me this _____ day of _________, 20_____ affiant exhibiting his/her Community Tax Certificate as indicated above.
(Person Administering Oath)

Forms 20 Saln

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SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL CONNECTIONS AND IDENTIFICATION OF RELATIVES

POSITION/INCOME : OFFICE : OFFICE ADDRESS : POSITION :

ADMIN. OFFICER IV HRDS, DENR- REGION XI LANANG, DAVAO CITY

SPOUSE'S NAME : REVILLA ( DECEASED) ROBERTO

DATE OF BIRTH N/A ____________________________________________

(paraphernal, conj ugal or community) -

1985 1988 2009 1994

P50,000.00 1,920,000.00 ACQUISITION COST, P P100,000.00 75,000.00

175,000.00 AMOUNT, P P 52,796.68 242,670.00 60,000.00 20,000.00 5,000.00

Total P NETWORTH (Total Assets 1A & 1B Less Liabilities (2))

NATURE OF BUSI NESS,

NAME OF FIRM/ COMPANY

I NTEREST AND/OR FI NANCI AL CONNECTI ON

DATE OF ACQUISITION/ CONNECTION

NAME Nora T. Alicante Nilda T. Pasay Felixberto V. Tequin

(Person Administering Oath)

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