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Saln 2012 Formsadsad

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Published by: ron1093a on Mar 18, 2014
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03/18/2014

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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
DECLARANT: (Family Name) ADDRESS: (First Name)

Separate Filing

Not Applicable

(M.I.)

POSITION: AGENCY/OFFICE: OFFICE ADDRESS:

SPOUSE: (Family Name) (First Name) (M.I.)

POSITION: 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*
KIND
(e.g. residential, commercial, industrial, agricultural and mixed use)

DESCRIPTION
(e.g. lot, house and lot, condominium and improvements)

LOCATION

ASSESSED VALUE

CURRENT FAIR MARKET VALUE

ACQUISITION YEAR MODE

ACQUISITION COST

(As found in the Tax Declaration of Real Property)

Subtotal: b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT

Subtotal : TOTAL ASSETS (a+b): 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.

Page 1 of ___

Include also Bilas. I hereby authorize the Ombudsman or his/her duly authorized representative to obtain and secure from all appropriate government agencies. 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. business interests and financial connections. business interests and financial connections.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. liabilities. day of . net worth. NAME OF ENTITY/BUSINESS ENTERPRISE BUSINESS ADDRESS NATURE OF BUSINESS INTEREST &/OR FINANCIAL CONNECTION DATE OF ACQUISITION OF INTEREST OR CONNECTION RELATIVES IN THE GOVERNMENT SERVICE (Within the Fourth Degree of Consanguinity or Affinity. Date: ______________________________ (Signature of Declarant) Government Issued ID: ID No. including the Bureau of Internal Revenue such documents that may show my assets. including those of my spouse and unmarried children below eighteen (18) years of age living in my household. the aboveenumerated are names of my relatives in the government within the fourth civil degree of consanguinity or affinity. and that to the best of my knowledge. affiant exhibiting to me the above-stated _______________________________________ (Person Administering Oath) Page 2 of ___ . 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. liabilities.: Date Issued: (Signature of Co-Declarant/Spouse) Government Issued ID: ID No.: Date Issued: SUBSCRIBED AND SWORN to before me this government issued identification card. net worth.

Real Properties KIND (e. Personal Properties DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT 2. lot. industrial. LIABILITIES AND NET WORTH 1. house and lot. ASSETS a.I.g. commercial. condominium and improvements) LOCATION ASSESSED VALUE CURRENT FAIR MARKET VALUE ACQUISITION YEAR MODE ACQUISITION COST (As found in the Tax Declaration of Real Property) b.) POSITION: AGENCY/OFFICE: ASSETS. LIABILITIES NATURE NAME OF CREDITORS OUTSTANDING BALANCE BUSINESS INTERESTS AND FINANCIAL CONNECTIONS NAME OF ENTITY/BUSINESS ENTERPRISE BUSINESS ADDRESS NATURE OF BUSINESS INTEREST &/OR FINANCIAL CONNECTION DATE OF ACQUISITION OF INTEREST OR CONNECTION Page __ of ___ .SWORN STATEMENT OF ASSETS. agricultural and mixed use) DESCRIPTION (e. 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) NAME: (Family Name) (First Name) (M. residential.g.

LIABILITIES AND NET WORTH As of ________________________________ (Sample additional sheet/s for the declarant) NAME: (Family Name) (First Name) (M. agricultural and mixed use) DESCRIPTION (e. industrial.g. house and lot.I. Real Properties KIND (e. Personal Properties DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT Subtotal : TOTAL ASSETS (a+b): 2. ASSETS a.SWORN STATEMENT OF ASSETS. commercial. LIABILITIES NATURE NAME OF CREDITORS OUTSTANDING BALANCE TOTAL LIABILITIES: BUSINESS INTERESTS AND FINANCIAL CONNECTIONS NAME OF ENTITY/BUSINESS ENTERPRISE BUSINESS ADDRESS NATURE OF BUSINESS INTEREST &/OR FINANCIAL CONNECTION DATE OF ACQUISITION OF INTEREST OR CONNECTION Page __ of ___ .g.) POSITION: AGENCY/OFFICE: ASSETS. LIABILITIES AND NET WORTH 1. lot. condominium and improvements) LOCATION ASSESSED VALUE CURRENT FAIR MARKET VALUE ACQUISITION YEAR MODE ACQUISITION COST (As found in the Tax Declaration of Real Property) Subtotal: b. residential.

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