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SALN Form Blank and Editable

This document is a sworn statement of assets, liabilities, and net worth that must be filed by public officials and employees in the Philippines according to Resolution No. 1500088. It was revised in January 2015 and requires the declarant, Yumul Geriel Perry M., a teacher, to disclose their assets, liabilities, business interests, relatives in government, and authorize the Ombudsman to access tax and other documents to verify the statement. The declarant affirms they have no spouse, children, businesses, financial connections, or relatives within the 4th degree of consanguinity or affinity working in the government.

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Kaeriee Macalia Yumul
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© © All Rights Reserved
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9K views

SALN Form Blank and Editable

This document is a sworn statement of assets, liabilities, and net worth that must be filed by public officials and employees in the Philippines according to Resolution No. 1500088. It was revised in January 2015 and requires the declarant, Yumul Geriel Perry M., a teacher, to disclose their assets, liabilities, business interests, relatives in government, and authorize the Ombudsman to access tax and other documents to verify the statement. The declarant affirms they have no spouse, children, businesses, financial connections, or relatives within the 4th degree of consanguinity or affinity working in the government.

Uploaded by

Kaeriee Macalia Yumul
Copyright
© © All Rights Reserved
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Revised as of January 2015

Per CSC Resolution No. 1500088


Promulgated on January 23, 2015

SWORNSTATEMENT 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: YUMUL GERIEL PERRY M. POSITION: TEACHER I


(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DEPARTMENT OF EDUCATION
ADDRESS: BLK. 13 LOT 33 ST. JAMES TERESA HOMES OFFICE ADDRESS:
SUBD. TIBAG TARLAC CITY

SPOUSE: N/A POSITION: N/A


(Family Name) (First Name) (M.I.) AGENCY/OFFICE: N/A
OFFICE ADDRESS: N/A

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD

NAME DATE OF BIRTH AGE


N/A N/A N/A

ASSETS,LIABILITIESANDNETWORTH
(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,
and improvements) agricultural and mixed (As found in the Tax Declaration of
Real Property)
YEAR MODE
use)

N/A N/A N/A N/A N/A N/A N/A N/A

Subtotal: 0
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_
2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

N/A N/A N/A

TOTAL LIABILITIES: 0
NET WORTH : Total Assets less Total Liabilities =
* Additional sheet/s may be used, if necessary.

BUSINESSINTERESTSANDFINANCIALCONNECTIONS
(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
N/A N/A N/A N/A

RELATIVESINTHEGOVERNMENTSERVICE
(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
N/A N/A N/A N/A

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: ___________________
N/A
(Signature of Declarant) (Signature of Co-Declarant/Spouse)

Government Issued ID: Government Issued ID: N/A


ID No.: ID No.: N/A
Date Issued: Date Issued: N/A

SUBSCRIBED AND SWORN to before me this ____ dayof____________ ,affiant exhibiting to me the above-
stated government issued identification card.

________________________

(Person Administering Oath)

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