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, and with postal address at

(Citizenship) (Civil Status)
after having duly sworn to in accordance with law hereby depose and say:

1. That I am the _________________________________ of the following real properties, (lands, buildings, machineries
(Owner or Administrator or Authorized Representative)
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 Lot Block Cadastral/ Area Classification Location of Property Total Current and
Title
Tax Dec. No. No. No. PLS No. Ha./Sq.M. (Res.,Agr.,Com.,etc.) (St./Dist./Barangay) Fair Market Value

B. BUILDING AND OTHER STRUCTURES

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

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

OTHER IMPROVEMENTS (Perennial Trees/Plants)

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