SALN

Revised 2013
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
As of _____________________
(Required by R. A. 6713
Jointly Filing Separate Filing Not Applicable
Note: Husband and wife are both public officials and employees may file the required statements jointly or separately.

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

Subtotal:

b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT

TOTAL ASSETS (a+b):

2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

TOTAL LIABILITIES:
###
NET WORTH: Total Assets Less Total Liabilities =

Additional sheets/may be used, if necessary.

Page 1 of ________
SALN
Revised 2013
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(of Declarant / Declarant's spouse/ Unmarried ChildrenBelow Eighteen (18) years of Age Living in Declarant's Household)
I/We do not have any business interest or financial connection.

NATURE OF BUSINESS
NAME OF ENTITY/BUSINESS DATE OF ACQUISITION OF
BUSINESS ADDRESS INTEREST &/OR FINANCIAL
ENTERPRISE INTEREST OR CONNECTION
CONNECTION

RELATIVES IN THE GOVERNMENT SERVICE

(Within the Fourth Degree of Consanguinity of 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 authorized 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 yeas 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 exhibiting to me the above-stated

government issued identification card.

_________________________________________
(Person Administering Oath)

Page 2 of ________
 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)

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

ASSETS, LIABILITIES AND NETWORTH

1. ASSETS
a. Real Properties*

DESCRIPTION KIND LOCATION ASSESSED CURRENT FAIR

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

b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT

2. LIABILITIES

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

NATURE OF BUSINESS
NAME OF ENTITY/BUSINESS DATE OF ACQUISITION OF
BUSINESS ADDRESS INTEREST &/OR FINANCIAL
ENTERPRISE INTEREST OR CONNECTION
CONNECTION
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