3.sample SALN Form Revised 2015
3.sample SALN Form Revised 2015
3.sample SALN Form Revised 2015
Note: Husband and wife who are both public officials and employees may file the required statements jointly or separately.
Joint 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
Subtotal: -
b. Personal Properties*
YEAR
DESCRIPTION ACQUISITION COST/AMOUNT
ACQUIRED
Subtotal: -
TOTAL ASSETS (a+b): -
2. LIABILITIES*
OUTSTANDING
NATURE NAME OF CREDITORS
BALANCE
Page 2 of 2
TOTAL LIABILITIES: -
* Additional sheet/s may be used, if necessary NET WORTH: Total Assets less Total Liabilities = -
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:
SUBSCRIBED AND SWORN to before me this _______ day of ____________________ , affiant exhibiting to me the above-stated
government issued identification card.
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:
1. ASSETS
a. Real Properties
ASSESSED CURRENT FAIR
DESCRIPTION KIND ACQUISITION
(e.g., residential, VALUE MARKET VALUE
EXACT ACQUISITION
(e.g. lot, house and lot, commercial,
LOCATION (As found in the Tax Declaration of COST
condominium, and industrial,
Real Property)
YEAR MODE
improvements) agricultural and
mixed used)
b. Personal Properties
YEAR
DESCRIPTION ACQUISITION COST/AMOUNT
ACQUIRED
2. LIABILITIES OUTSTANDING
NATURE NAME OF CREDITORS
BALANCE
NAME: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:
1. ASSETS
a. Real Properties
ASSESSED CURRENT FAIR
DESCRIPTION KIND ACQUISITION
VALUE MARKET VALUE
(e.g., residential, EXACT ACQUISITION
(e.g. lot, house and lot, commercial,
LOCATION (As found in the Tax Declaration of COST
condominium, and industrial,
Real Property)
YEAR MODE
improvements) agricultural and
mixed used)
Subtotal: -
b. Personal Properties
YEAR
DESCRIPTION ACQUISITION COST/AMOUNT
ACQUIRED
Subtotal: -
TOTAL ASSETS (a+b): -
2. LIABILITIES OUTSTANDING
NATURE NAME OF CREDITORS
BALANCE
TOTAL LIABILITIES: -