Sample Saln 6h3z1c

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of

January 1, 2015

DECLARANT:

ADDRESS:

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)

ASSESSED VALUE

CURRENT FAIR MARKET VALUE

ACQUISITION ACQUISITI ON COST

LOCATION YEAR

MODE

Subtotal:

b. Personal Properties

XXXX

DESCRIPTION Cash in Bank

YEAR ACQUIRED

ACQUISITION COST/AMOUNT

2015

xxxxxx

Subtotal: TOTAL ASSETS (a+b):

#VALUE!

2. LIABILITIES* NATURE

NAME OF CREDITORS

OUTSTANDING BALANCE

TOTAL LIABILITIES: NET WORTH: Total Assets less Total Liabilities =

I hereby certify that these are true and correct statements of my assets, liabilities, net worth. Date:

(Signature of Declarant)

SUBSCRIBED AND SWORN to before me this _______ day of ____________________ , affiant exhibiting to me the above-stated government issued identification card.

(Person istering Oath)

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