3.sample Saln Form Revised 2015 2k6a
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Revised as of January 2015 Per CSC Resolution No. 1500088 Promulgated on January 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of
(Required by R.A. 6713)
Note: Husband and wife who are both public officials and employees may file the required statements tly or separately. t Filing Separate Filing Not Applicable DECLARANT:
POSITION: (Family Name)
(First Name)
(M
AGENCY/OFFICE: OFFICE ADDRESS:
ADDRESS: SPOUSE:
POSITION: (Family Name )
(First Name)
(
AGENCY/OFFICE: OFFICE ADDRESS:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT'S HOUSEHOLD NAME
DATE OF BIRTH
AGE
ASSETS, LIABILITIES AND NETWORTH (Including those of the spouse and unmarried children below eighteen (18) years of age living in declarant's household) 1. ASSETS a. Real Properties* DESCRIPTION
KIND
(e.g. lot, house and lot, condominium, and improvements)
(e.g., residential, commercial, industrial, agricultural and mixed used)
EXACT LOCATION
ASSESSED VALUE
CURRENT FAIR MARKET VALUE
(As found in the Tax Declaration of Real Property)
ACQUISITION
YEAR MODE
ACQUISITION COST
Subtotal:
b. Personal Properties*
YEAR ACQUIRED
DESCRIPTION
ACQUISITION COST/AMOUNT
Subtotal: TOTAL ASSETS (a+b):
2. LIABILITIES* NATURE
NAME OF CREDITORS
Page 2 of 2
-
OUTSTANDING BALANCE
-
-
TOTAL LIABILITIES: * Additional sheet/s may be used, if necessary
NET WORTH: Total Assets less Total Liabilities =
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (of Declarant/Declarant's Spouse/Unmarried Children Below Eighteen (18) years of Age Living in Declarant's Household) I/We do not have any business interest or financial connection. NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
NATURE OF BUSINESS INTEREST & / OR FINANCIAL CONNECTION
DATE OF ACQUISITION OF INTEREST OR CONNECTION
RELATIVES IN THE GOVERNMENT SERVICE (Within the Fourth Degree of Consanguinity or Affinity, Include also Bilas, Balae and Inso) I/We do not know of any relative/s in the government service NAME OF RELATIVE
RELATIONSHIP
POSITION
NAME OF AGENCY/OFFICE AND ADDRESS
I hereby certify that these are true and correct statements of my assets, liabilities, net worth, business interests and financial connections, including those of my spouse and unmarried children below eighteen (18) years of age living in my household, and that to the best of my knowledge, the above-enumerated are names of my relatives in the government within the fourth civil degree of consanguinity or affinity. I hereby authorize the Ombudsman or his/her 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 previous years to include the year I first assumed office in government. Date:
(Signature of Declarant)
(Signature of Co-Declarant/Spouse)
Government Issued ID:
Government Issued ID:
ID No:
ID No.:
Date Issued:
Date Issued:
SUBSCRIBED AND SWORN to before me this _______ day of ____________________ , affiant exhibiting to me the above-stated government issued identification card.
(Person istering Oath)
Page 2 of 2
Revised as of January 2015 Per CSC Resolution No. 1500088 Promulgated on January 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of (Sample additional sheet/s for the exclusive properties of the declarant's spouse and unmarried children below eighteen (18) years of age living in declarant's household)
NAME:
POSITION: (Family Name)
(First Name)
(M.I.)
AGENCY/OFFICE:
ASSETS, LIABILITIES AND NETWORTH 1. ASSETS a. Real Properties DESCRIPTION
KIND
(e.g. lot, house and lot, condominium, and improvements)
(e.g., residential, commercial, industrial, agricultural and mixed used)
EXACT LOCATION
ASSESSED CURRENT FAIR ACQUISITION VALUE MARKET VALUE (As found in the Tax Declaration of Real Property)
YEAR MODE
ACQUISITION COST
b. Personal Properties YEAR ACQUIRED
DESCRIPTION
2. LIABILITIES
NATURE
ACQUISITION COST/AMOUNT
NAME OF CREDITORS
OUTSTANDING BALANCE
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
Page _____ of ______
NATURE OF BUSINESS INTEREST & / OR FINANCIAL CONNECTION
DATE OF ACQUISITION OF INTEREST OR CONNECTION
Revised as of January 2015 Per CSC Resolution No. 1500088 Promulgated on January 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of (Sample additional sheet/s for the declarant)
NAME:
(Family Name)
(First Name)
(M.I.)
POSITION: AGENCY/OFFICE:
ASSETS, LIABILITIES AND NETWORTH 1. ASSETS a. Real Properties DESCRIPTION
KIND
(e.g. lot, house and lot, condominium, and improvements)
(e.g., residential, commercial, industrial, agricultural and mixed used)
EXACT LOCATION
ASSESSED CURRENT FAIR ACQUISITION VALUE MARKET VALUE (As found in the Tax Declaration of Real Property)
YEAR MODE
ACQUISITION COST
Subtotal: b. Personal Properties
YEAR ACQUIRED
DESCRIPTION
-
ACQUISITION COST/AMOUNT
Subtotal: TOTAL ASSETS (a+b): 2. LIABILITIES
NATURE
NAME OF CREDITORS
TOTAL LIABILITIES:
-
OUTSTANDING BALANCE
-
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
Page _____ of ______
NATURE OF BUSINESS INTEREST & / OR FINANCIAL CONNECTION
DATE OF ACQUISITION OF INTEREST OR CONNECTION
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of
(Required by R.A. 6713)
Note: Husband and wife who are both public officials and employees may file the required statements tly or separately. t Filing Separate Filing Not Applicable DECLARANT:
POSITION: (Family Name)
(First Name)
(M
AGENCY/OFFICE: OFFICE ADDRESS:
ADDRESS: SPOUSE:
POSITION: (Family Name )
(First Name)
(
AGENCY/OFFICE: OFFICE ADDRESS:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT'S HOUSEHOLD NAME
DATE OF BIRTH
AGE
ASSETS, LIABILITIES AND NETWORTH (Including those of the spouse and unmarried children below eighteen (18) years of age living in declarant's household) 1. ASSETS a. Real Properties* DESCRIPTION
KIND
(e.g. lot, house and lot, condominium, and improvements)
(e.g., residential, commercial, industrial, agricultural and mixed used)
EXACT LOCATION
ASSESSED VALUE
CURRENT FAIR MARKET VALUE
(As found in the Tax Declaration of Real Property)
ACQUISITION
YEAR MODE
ACQUISITION COST
Subtotal:
b. Personal Properties*
YEAR ACQUIRED
DESCRIPTION
ACQUISITION COST/AMOUNT
Subtotal: TOTAL ASSETS (a+b):
2. LIABILITIES* NATURE
NAME OF CREDITORS
Page 2 of 2
-
OUTSTANDING BALANCE
-
-
TOTAL LIABILITIES: * Additional sheet/s may be used, if necessary
NET WORTH: Total Assets less Total Liabilities =
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (of Declarant/Declarant's Spouse/Unmarried Children Below Eighteen (18) years of Age Living in Declarant's Household) I/We do not have any business interest or financial connection. NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
NATURE OF BUSINESS INTEREST & / OR FINANCIAL CONNECTION
DATE OF ACQUISITION OF INTEREST OR CONNECTION
RELATIVES IN THE GOVERNMENT SERVICE (Within the Fourth Degree of Consanguinity or Affinity, Include also Bilas, Balae and Inso) I/We do not know of any relative/s in the government service NAME OF RELATIVE
RELATIONSHIP
POSITION
NAME OF AGENCY/OFFICE AND ADDRESS
I hereby certify that these are true and correct statements of my assets, liabilities, net worth, business interests and financial connections, including those of my spouse and unmarried children below eighteen (18) years of age living in my household, and that to the best of my knowledge, the above-enumerated are names of my relatives in the government within the fourth civil degree of consanguinity or affinity. I hereby authorize the Ombudsman or his/her 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 previous years to include the year I first assumed office in government. Date:
(Signature of Declarant)
(Signature of Co-Declarant/Spouse)
Government Issued ID:
Government Issued ID:
ID No:
ID No.:
Date Issued:
Date Issued:
SUBSCRIBED AND SWORN to before me this _______ day of ____________________ , affiant exhibiting to me the above-stated government issued identification card.
(Person istering Oath)
Page 2 of 2
Revised as of January 2015 Per CSC Resolution No. 1500088 Promulgated on January 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of (Sample additional sheet/s for the exclusive properties of the declarant's spouse and unmarried children below eighteen (18) years of age living in declarant's household)
NAME:
POSITION: (Family Name)
(First Name)
(M.I.)
AGENCY/OFFICE:
ASSETS, LIABILITIES AND NETWORTH 1. ASSETS a. Real Properties DESCRIPTION
KIND
(e.g. lot, house and lot, condominium, and improvements)
(e.g., residential, commercial, industrial, agricultural and mixed used)
EXACT LOCATION
ASSESSED CURRENT FAIR ACQUISITION VALUE MARKET VALUE (As found in the Tax Declaration of Real Property)
YEAR MODE
ACQUISITION COST
b. Personal Properties YEAR ACQUIRED
DESCRIPTION
2. LIABILITIES
NATURE
ACQUISITION COST/AMOUNT
NAME OF CREDITORS
OUTSTANDING BALANCE
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
Page _____ of ______
NATURE OF BUSINESS INTEREST & / OR FINANCIAL CONNECTION
DATE OF ACQUISITION OF INTEREST OR CONNECTION
Revised as of January 2015 Per CSC Resolution No. 1500088 Promulgated on January 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of (Sample additional sheet/s for the declarant)
NAME:
(Family Name)
(First Name)
(M.I.)
POSITION: AGENCY/OFFICE:
ASSETS, LIABILITIES AND NETWORTH 1. ASSETS a. Real Properties DESCRIPTION
KIND
(e.g. lot, house and lot, condominium, and improvements)
(e.g., residential, commercial, industrial, agricultural and mixed used)
EXACT LOCATION
ASSESSED CURRENT FAIR ACQUISITION VALUE MARKET VALUE (As found in the Tax Declaration of Real Property)
YEAR MODE
ACQUISITION COST
Subtotal: b. Personal Properties
YEAR ACQUIRED
DESCRIPTION
-
ACQUISITION COST/AMOUNT
Subtotal: TOTAL ASSETS (a+b): 2. LIABILITIES
NATURE
NAME OF CREDITORS
TOTAL LIABILITIES:
-
OUTSTANDING BALANCE
-
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
Page _____ of ______
NATURE OF BUSINESS INTEREST & / OR FINANCIAL CONNECTION
DATE OF ACQUISITION OF INTEREST OR CONNECTION
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