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    Sworn Statement of Assets, Liabilities and Net Worth

    Uploaded by

    Jules Aguilay

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Sworn Statement of Assets, Liabilities and Net Worth

    Uploaded by

    Jules Aguilay
    84 views3 pages

    Original Title

    SALN2015Form.doc

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    © © All Rights Reserved

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    © All Rights Reserved
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    84 views3 pages

    Sworn Statement of Assets, Liabilities and Net Worth

    Uploaded by

    Jules Aguilay

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 3

    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 jointly or separately.

    Joint Filing

    Separate Filing

    DECLARANT

    Not Applicable

    POSITION:

    :
    (Family Name)

    (First Name)

    (M.I.)

    ADDRESS:

    AGENCY/OFFICE:
    OFFICE ADDRESS:

    SPOUSE:

    POSITION:
    (Family Name)

    (First Name)

    (M.I.)

    AGENCY/OFFICE:
    OFFICE ADDRESS:

    UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANTS 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 declarants 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
    use)

    LOCATION

    ASSESSED

    CURRENT FAIR

    VALUE

    MARKET VALUE

    (As found in the Tax Declaration of


    Real Property)

    ACQUISITION
    YEAR

    ACQUISITION COST

    MODE

    Subtotal:

    b. Personal Properties*
    DESCRIPTION

    YEAR ACQUIRED

    Subtotal :

    Page 1 of ___

    ACQUISITION COST/AMOUNT

    TOTAL ASSETS (a+b):


    * Additional sheet/s may be used, if necessary.
    2. LIABILITIES*
    NATURE

    NAME OF CREDITORS

    OUTSTANDING BALANCE

    TOTAL LIABILITIES:
    NET WORTH : Total Assets less Total Liabilities =
    * Additional sheet/s may be used, if necessary.

    BUSINESS INTERESTS AND FINANCIAL CONNECTIONS


    (of Declarant /Declarants spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarants 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 aboveenumerated 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)
    Government Issued ID:

    (Signature of Co-Declarant/Spouse)
    Government Issued ID:

    Page 2 of ___

    ID No.:
    Date Issued:

    ID No.:
    Date Issued:

    SUBSCRIBED AND SWORN to before me this


    government issued identification card.

    day of

    , affiant exhibiting to me the above-stated

    _______________________________________
    (Person Administering Oath)

    Page 3 of ___

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