SWORN STATEMENT INDEX NO.

SWORN STATEMENT OF THE TRUE CURRENT AND FAIR MARKET VALUE OF REAL PROPERTIES
(Taxable or Exempt) (Required under Section 202/203 of Republic Act No. 7160) I, , of legal age,
(Citizenship) (Civil Status)

and with postal address at

after having duly sworn to in accordance with law hereby depose and say: 1. That I am the _________________________________
(Owner or Administrator or Authorized Representative)

of the following real properties, (lands, buildings, machineries

or other improvements) located in the city/municipality of _______________________, province of _______________________ owned by ________________________________________________ of which the description and true current and fair market
(State Name of Owner/s if filed by administrative or authorized representative

value/s are as follows: A. LAND (Residential, Commercial, Industrial, Agricultural, Special)

Existing Tax Dec. No. Lot No. Block No. Cadastral/ PLS No. Title Classification Area Location of Property Ha./Sq.M. (Res.,Agr.,Com.,etc.) (St./Dist./Barangay) Total Current and Fair Market Value

B. BUILDING AND OTHER STRUCTURES

Total Year No. Actual Existing General Description Completed/ Floor Area Storey Use Tax Dec. No. in (Sq.M.) Occupied Owner of Lot Where Bldg. is Located Location of Property (No./St./ Dist./Barangay) True Current and Fair Market Value

C. MACHINERIES
Existing Tax Dec. No. Description Date Acquired Commenced Operation Original Acquisition Cost Cost of Installation Site Value of Depreciation Location of Property (No./St./ Dist./Barangay) True Current and Fair Market Value

OTHER IMPROVEMENTS (Perennial Trees/Plants)

Existing Tax Dec. No. Kinds of Trees/Plants No. of Trees/ Hec./ Productive Annual Product per Tree/Plant No. of Trees/ True Current and Fair Market Value Hec. & Ages Productive Non-Productive Non-Productive

2.

That I am executing this sworn statement in compliance with Republic Act No. 7160

IN WITNESS WHEREOF, I have hereunto affixed my signature this ____ day of ___________, ______ at __________, if thumbmarks require signatures of two (2) witnesses: Signature (Witness) (Witness) TIN

SUBSCRIBED AND SWORN to before me this ____ day of ___________, 20___, affiant exhibiting his/her Community Tax Certificate No. A-_____________ issued on _____________ at _________________, Philippines.

(Signature of Administering Officer) TIN

Note:
1) Include in this sworn statement only real property owned or administered by the affiant in one municipality or city. 2) Prepare three (3) copies and after having been subscribed to by the affiant, submit the same to the Provincial, City, Municipal Assessor or Municipal Deputy Assessor or Ex-Officio Deputy Assessor of the province, city or municipality where the property is located; the original and duplicate to be retained by receiving office and the triplicate to be returened to the affiant after receipt thereof has been duly acknowledged. 3) Write "NEW" under column "Existing Tax Dec. No." for property not previously declared. 4) Original acquisition cost of Machinery include such costs as freight and insurance charges, brokerage, arrastre and handling, custom duties and taxes, cost of inland transportation and handling. 5) Write additional information in another sheet, if necessary.