QCG-CAO-QP/SOI-E01-v01 Last revised 6/22/2018

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

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

I, JOEMEN A. RIVERA, of legal age, single and with postal address

at UNIT 109,BUILDING I,CAMARIN RESIDENCES CALOOCAN CITY, after having been duly sworn to in accordance with law, depose and say:

1. That I am the REPRESENTATIVE of the following real properties (lands, buildings, machineries, and other
improvements) located in the City/Municipality of QUEZON CITY , Metro Manila, owned by NEW SAN JOSE BUILDERS INC.
__________________________________________________________________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 &
Lot No. Block No. TITLE No.
Dec. No. Pls.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. Year Owner of Lot Where Bldg is Location of Property True Current &
General Description Completed/O Actual Use
Dec. No. in sq.m. Storey ccupied Constructed (St./Dist./Barangay) Fair Market Value
G-110-04483 21.96 32TH CONDOMINUIM NEW SAN JOSE BUILDERS INC. EDSA & SGT ESGUERRA AVE 411,090.00
SOUTH TRIANGLE QUEZON CITY
P
P
P
C. MACHINERIES
Existing Tax DATE ORIGINAL VALUE OF TRUE CURRENT & FAIR
DESCRIPTION ACQUISITION COST OF
DEPRECIATION PLACE OF INSTALLATION
Dec. No. ACQUIRED COMMENCED
OPERATION
COST INSTALLATION ON
SITE 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
KINDS OF TREES/PLANTS
Dec. No. 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 proof 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; cost of inland transportation and handling.
(5) Write additional information in another sheet, if necessary.
Note:
(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 proof 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; cost of inland transportation and handling.
(5) Write additional information in another sheet, if necessary.