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    Saln Form 2023

    Uploaded by

    Arnel B. Presto

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Saln Form 2023

    Uploaded by

    Arnel B. Presto
    19 views2 pages

    Copyright

    © © All Rights Reserved

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    DOC, PDF, TXT or read online from Scribd

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    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    19 views2 pages

    Saln Form 2023

    Uploaded by

    Arnel B. Presto

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    You are on page 1of 2

    Revised as of January 2015

    Per CSC Resolution No. 1500088


    Promulgated on January 23, 2015

    SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH


    As of December 31, 2023
    (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 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*

    DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION


    (e.g. lot, house and lot, VALUE MARKET VALUE
    condominium and
    (e.g. residential, commercial, LOCATION COST
    industrial, agricultural and mixed
    improvements) (As found in the Tax Declaration of
    use)
    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.

    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.


    Page 1 of 2
    NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS INTEREST DATE OF ACQUISITION OF
    ENTERPRISE &/OR FINANCIAL CONNECTION 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 ____________, 2024 affiant exhibiting to me the above-stated
    government issued identification card.

    JESSAMYN D. VALLEDOR
    Administrative Officer IV
    (Person Administering Oath)

    Page 2 of 2

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