Revised saln2012 form 1-1
Download as DOC, PDF
2 likes3,692 views
This document is a sworn statement of assets, liabilities, and net worth that must be filed by public officials and employees under Philippine law. It requires the declarant to disclose their personal and real property assets and liabilities, as well as any business interests or relatives employed by the government. At the end, the declarant authorizes the Ombudsman to obtain tax and financial records to verify the accuracy of the statement.
Revised saln2012 form 1-1
- 1. 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 Separate Filing Not Applicable DECLARANT: POSITION: (Family Name) (First Name) (M.I.) AGENCY/OFFICE: ADDRESS: OFFICE ADDRESS: SPOUSE: POSITION: (Family Name) (First Name) (M.I.) AGENCY/OFFICE: OFFICE ADDRESS: UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANTS 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 declarants household) 1. ASSETS a. Real Properties* DESCRIPTION (e.g. lot, house and lot, condominium and improvements) KIND (e.g. residential, commercial, industrial, agricultural and mixed use) LOCATION ASSESSED VALUE CURRENT FAIR MARKET VALUE ACQUISITION ACQUISITION COST (As found in the Tax Declaration of Real Property) YEAR MODE 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 ___
- 2. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (of Declarant /Declarants spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarants Household) I/We do not have any business interest or financial connection. 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. Include also 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. _______________________________________ (Person Administering Oath) Page 2 of ___