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Sworn Statement of Assets, Liabilities and Net Worth (Saln) : Joint Filing Separate Filing Not Applicable
Sworn Statement of Assets, Liabilities and Net Worth (Saln) : Joint Filing Separate Filing Not Applicable
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”.
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
Total Value of Real Properties (Including those declared in the Additional Sheet, if any): P
2
b. Personal Properties
Total Value of Personal Properties (Including those declared in the Additional Sheet, if any):
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
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: _______________________
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)
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:
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ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION
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)
Total Value of Real Properties of the Declarant’s Spouse and Unmarried Children:
Total Value of Personal Properties of the Declarant’s Spouse and Unmarried Children:
B. LIABILITIES (Separate)
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