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    2015 SALN Form

    Uploaded by

    Josam Montero Ford

    Copyright:

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

    2015 SALN Form

    Uploaded by

    Josam Montero Ford
    9 views3 pages

    Original Title

    2015-SALN-Form.doc

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    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
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    Download as doc, pdf, or txt
    9 views3 pages

    2015 SALN Form

    Uploaded by

    Josam Montero Ford

    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  Not Applicable

    DECLARANT: POSITION:
    (Family Name) (First Name) (M.I.) AGENCY/OFFICE:
    ADDRESS: OFFICE ADDRESS:

    SPOUSE: POSITION:
    (Family Name) (First Name) (M.I.) 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 EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION


    (e.g. lot, house and (e.g. residential, LOCATION VALUE MARKET VALUE COST
    lot, condominium commercial, industrial,
    (As found in the Tax Declaration of
    and improvements) agricultural and mixed YEAR MODE
    use) Real Property)

    Subtotal:
    b. Personal Properties*

    DESCRIPTION YEAR ACQUIRED ACQUISITION


    COST/AMOUNT

    Subtotal :

    TOTAL ASSETS (a+b):


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

    Page 1 of ___
    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 /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 BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF


    ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
    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.

    _______________________________________

    Page 2 of ___
    (Person Administering Oath)

    Page 3 of ___

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