HRep SALN Form (2019)

Per House Resolution No. 176

(Adopted from the 2015 CSC SALN Form)

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH (SALN)

As of December 31, 2021
(Required by R.A. 6713 and House Resolution No. 176)

Note: Husband and wife who are both public officials/employees may file their SALN jointly or separately. The declarant who is single,
widowed, divorced or annulled or married to a private person shall tick off the box marked below as “Not Applicable”.

 Joint Filing  Separate Filing  Not Applicable

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

SPOUSE: POSITION:
(Family Name) (First Name) (M.I.) OFFICE:
OFFICE ADDRESS:

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

NAME DATE OF BIRTH AGE

ASSETS, LIABILITIES AND NETWORTH

(Properties owned by the abovenamed unmarried children and exclusive properties of the declarant’s spouse, in case
of separate filing, must be declared in the Separate Sheet/s)
1. ASSETS
a. Real Properties1

DESCRIPTIO KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION

N (e.g. Residential, LOCATION VALUE MARKET COST
Commercial, Industrial,
(e.g. Lot, House Agricultural and Mixed VALUE
and Lot, Use)
As found in the Latest As found in the Latest
Condominium and YEAR MODE
Improvement) Tax Declaration BIR Zonal Value

Total Value of Real Properties (Including those declared in the Additional Sheet, if any): ₽
2
b. Personal Properties

DESCRIPTION ACQUISITION ACQUISITION

COST/AMOUNT
YEAR MODE

Total Value of Personal Properties (Including those declared in the Additional Sheet, if any): ₽

Total Assets (a + b): ₽

1
Additional Sheet/s may be used, if necessary. In case of joint filing, the list should include the exclusive properties of the spouse.
2
Additional Sheet/s may be used, if necessary. In case of joint filing, the list should include the exclusive properties of the spouse.
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 2. LIABILITIES3

NATURE NAME OF CREDITORS OUTSTANDING

BALANCE

Total Liabilities (Including those declared in the Additional Sheet, if any): ₽

NET WORTH (Total Assets - Total Liabilities): ₽

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS4

(Business interests and financial connections of the spouse and unmarried children, if any, should be declared in the Separate Sheet/s)

 I/We do not have any business interest or financial connection .

NAME OF BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF

ENTITY/ENTERPRISE INTEREST OR FINANCIAL INTEREST OR CONNECTION
CONNECTION

RELATIVES IN THE GOVERNMENT SERVICE5

(Within the Fourth Degree of Consanguinity or Affinity, including 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.

_______________________________________

3
Additional Sheet/s may be used, if necessary.
4
Additional Sheet/s may be used, if necessary.
5
Additional Sheet/s may be used, if necessary.
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 (Person Administering Oath)

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH (SALN)

As of 31 December 2019
(Required by R.A. 6713 and House Resolution No. 176)

ADDITIONAL SHEET
Note: This Additional Sheet may be used to declare additional list of declarant’s assets, liabilities and financial interests and
financial connections, including those of the declarant’s spouse in case of joint filing.

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

1.a. Declarant’s Real Properties (Additional)

DESCRIPTIO KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION

N (e.g. residential, LOCATION VALUE MARKET COST
commercial,
(e.g. lot, house and industrial, agricultural VALUE
lot, condominium and mixed use) As found in the Latest As found in the Latest
and improvement)
Tax Declaration BIR Zonal Value
YEAR MODE

Subtotal of Real Properties Declared in this Additional List:

1.b. Declarant’s Personal Properties (Additional)

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

Subtotal of Personal Properties Declared in this Additional List:

2. LIABILITIES (Additional List)

NATURE NAME OF CREDITORS OUTSTANDING

BALANCE

Subtotal of Liabilities Declared in this Additional List:

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (Additional)

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF

ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION

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 SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH (SALN)
As of 31 December 2019
(Required by R.A. 6713 and House Resolution No. 176)

SEPARATE SHEET
Note: This Separate Sheet shall be used in declaring (1) exclusive properties of the declarant’s spouse except in case of
joint filing; (2) properties owned by the declarant’s unmarried children below 18 years of age living in the declarant’s
household; and (3) their business interests and financial connections.

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

A. ASSETS
1. Real Properties (Separate)

DESCRIPTIO KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION

N (e.g. residential, LOCATION VALUE MARKET COST
commercial,
(e.g. lot, house and industrial, agricultural VALUE
lot, condominium and mixed use) As found in the Latest As found in the Latest
and improvement)
Tax Declaration BIR Zonal Value
YEAR MODE

Total Value of Real Properties of the Declarant’s Spouse and Unmarried Children:

2. Personal Properties (Separate)

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

Total Value of Personal Properties of the Declarant’s Spouse and Unmarried Children:

B. LIABILITIES (Separate)

NATURE NAME OF CREDITORS OUTSTANDING

BALANCE

Total Personal Liabilities of the Declarant’s Spouse:

C. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (Separate)

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF

ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION

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