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2012 SALN Form.xlsx

2012 SALN Form.xlsx

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SALN 2012 version MS Excel file
SALN 2012 version MS Excel file

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Published by: Rimel Dizon Evaristo on Mar 13, 2013
Copyright:Attribution Non-commercial

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02/06/2014

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As of  Joint FilingSeparate FilingNot Applicable
DECLARANT:POSITION:AGENCY/OFFICE:ADDRESS:OFFICE ADDRESS:SPOUSE:POSITION:AGENCY/OFFICE:OFFICE ADDRESS:
1.ASSETSa.Real Properties*
PPPP
 b.Personal Properties*
PP
2.LIABILITIES
 
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
(Required by R.A. 6713)(First Name)(M.I.)(Family Name)
ASSETS, LIABILITIES AND NETWORTH
(Including those of the spouse and unmarried children below eighteen (18) years of age living in declarant's household)
Note
:
Husband and wife who are both public officials and employees may file the required statements jointly or separately.
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT'S HOUSEHOLD
NAMEDATE OF BIRTHAGE
(Family Name)(First Name)(M.I.)
 
ACQUISITIONMARKET VALUECURRENT FAIR
Subtotal:
YEAR
 
COSTMODEDESCRIPTION
(e.g. lot house and lot,condominuim andimprovements)
KIND
(e.g. residential,commercial, industrial,agricultural & mixeduse)
LOCATION
(As found in the Tax Declaration of Real Property)
ASSESSEDVALUEACQUISITION COSTAMOUNTDESCRIPTIONYEAR ACQUIRED
TOTAL ASSETS (a+b):Subtotal:
NAME OF CREDITORSNATURE
 
OUTSTANDINGBALANCE
 
PPP
*Additional sheet/s may be used, if necessary.
business interests and financial connections, including those of my spouse and unmarried children beloweighteen (18) years of age living in my household, and that to the best of my knowledge, the above-enumeratedare names of my relatives in the government within the fourth civil degree of consanguinity or affinity.secure from all appropriate government agencies, including the Bureau of Internal Revenue such documentsthat 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 coveringprevious years to include the year I first assumed office in government.
Date:
 NET WORTH: Total Assets less Total Liabilities:TOTAL LIABILITIES:
INTEREST &/or FINANCIAL CONNECTIONOF INTERESTCONNECTIONNAME OF ENTITYBUSINESS ADDRESS
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.
NATURE OF BUSINESSDATE OF ACQUISITION
I/We do not know any relative/s in the government service
RELATIVES IN THE GOVERNMENT SERVICE
(within the Fourth Degree of Consanguinity or Affinity. Include also Bilas, Balae and Inso)
I hereby authorize the Ombudsman or his/her duly authorized representative to obtain and
RELATIONSHIPNAME OF RELATIVE
I hereby certify that these are true and correct statements of my assets, liabilities, net worth,
POSITIONNAME OF AGENCY/OFFICE ADDRESS
 
Government Issued ID: Government Issued ID:ID No.:ID No.:Date Issued: Date Issued:
SUBSCRIBED AND SWORN
to before me this, affiantexhibiting exhibiting to me the above-stated government issued identification card.day of 
(Person Administering Oath) (Signature of Declarant)(Signature of Co-Declarant / Spouse

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