SALN
Revised 2013
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
Asof - _—_
(Required by RA. 6713)
Note: Husband and wife who are both publi officials and employees may file the required statements jointly or separately
@ Joint Filing 8 Separate Filing 9 Not Applicable
DECLARANT: - POSITION: _ -
~ Family Name) Tris Namer ST) AGENCY/OFFICE:
ADDRESS: _ OFFICE ADDRESS: -
SPOUSE: PosITIow: -
- ‘AGENCY /OFFICE:
‘OFFICE ADDRESS:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
vane bate oF nina foe
ASSETS, LIABILITIES AND NETWORTH
(inctuding those ofthe spouse and unmarried cldren below eighteen (18)
tears of age hung in declarant’ household)
1. ASSETS:
a Real Propertiost
puscurnon| xm | vocariow] assessep | cummewr rain | acqusrion | ACQUISTION cost
‘emia’ | teri van | sunesr wae
Esmee | sats onigetemeens | waa | woos
b. Personal Properties"
2.
NAME OF CREDITORS
“TOTAL LIABILITIES:
NET WORTH : Total Assets less Total Liabilities =
* Additional sheet/s may be used, if necessary.
Page | ofSALN
Revised 2013
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
{of Declarant /Dectarant's spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarant’s Household)
6 1/We do not have any business interest or financial connection.
MAME OF ENTITY/BUSINESS ‘BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF
ENTERPRISE INTEREST &/OR FINANCIAL | INTEREST OR CONNECTION
‘CONNECTION
RELATIVES IN THE GOVERNMENT SERVICE
[Within the Fourth Degree of Consanguinity or Affinity. Inchude also Bilas, Balae and nso}
8 1/ We do not know of any relative/s in the government service)
RELATIONSHIP Posrrion
NAME OF RELATIVE,
[NAME OF AGENCY/OFFICE AND ADDRESS
Thereby 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)
Government Issued ID:
IN
Date Issued:
SUBSCRIBED AND SWORN to before me this __day of
government issued identification card.
Signature of Co-Dedlarani/Spouse)
Government Issued Ib:
1D No.
Date Issued:
affiant exhibiting to me the above-stated
(Person Administering Oath)
Page 2of __SALN
Revised 2013
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}
NAME: POSITION:
amily Namel ‘(First Name] wey AGENCY /OFFICE:
ASSETS, LIABILITIES AND NET WORTH
1. ASSETS
Real Properties
‘NAME OF CREDITORS: ‘OUTSTANDING BALANCE
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
AME OF ENTITY /BUSIVESS BUSINESS ADDRESS NATURE OF BUSINESS. DATE OF ACQUISITION OF
ENTERPRISE INTEREST &/OR FINANCIAL | INTEREST OR CONNECTION
‘CONNECTION
Page ofSALN
Revised 2013
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH
Asof _
(Sample additional sheet/s for the declarant)
NAME: Postrion:
‘Family None) (Frame) (HUTT ——AGENCY/oFFICE: -
ASSETS, LIABILITIES AND NET WORTH
1. ASSETS
a. Real Properties
pescripnion| mp | Locamion| assessen | cunnenrram | ACQUISITION | ACQUISITION cost
Newent | oem vawue | warscer VALUE
YEAR | MODE
sc improvenens | Sgciarl and med Ussund in tieTax Dechraton ol |
eal ope |
‘TOTAL LIABILITIES:
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
‘NAME OF ENTITY /BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF
ENTERPRISE INTEREST &/OR FINANCIAL | INTEREST OR CONNECTION
‘CONNECTION
Page of