2015 Saln Form - Guide

Revised as of January 2015
Per CSC Resolution No. 1500088

1. PLEASE PROVIDE 3 COPIES OF THE SALN
Promulgated on January 23, 2015
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

As of ________________________________ <---- 2. PLEASE WRITE YOUR
(Required by R.A. 6713) ASSUMPTION DATE
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 <---- 3. PLEASE CHECK
THE APPROPRIATE BOX
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:
4. PLEASE FILL UP THE BLANKS, IF NOT
APPLICABLE WRITE N/A
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NAME DATE OF BIRTH AGE
5. PLEASE FILL UP THE BLANKS, IF NOT APPLICABLE WRITE N/A
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 (e.g. residential, LOCATION VALUE MARKET VALUE COST
lot, condominium commercial, industrial,
(As found in the Tax Declaration of
and improvements) agricultural and mixed
Real Property)
YEAR MODE
use)
6. PLEASE FILL UP THE BLANKS, IF NOT APPLICABLE WRITE N/A IN ALL THE BOXES
Subtotal: 0.00
b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT
Subtotal :
TOTAL ASSETS (a+b):

* Additional sheet/s may be used, if necessary.
Page 1 of ___ <---- 8. Page of how many ?

2. LIABILITIES*
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
TOTAL LIABILITIES: 0.00

NET WORTH : Total Assets less Total Liabilities = 0.00
* Additional sheet/s may be used, if necessary. ---->
10.
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

(of Declarant /Declarant’s spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarant’s Household)
<---- 11. PLEASE CHECK
 I/We do not have any business interest or financial connection.
THE APPROPRIATE BOX
NAME 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. Include also Bilas, Balae and Inso)
<---- 13. PLEASE CHECK
 I/We do not know of any relative/s in the government service)
THE APPROPRIATE BOX
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: ______________________________
16. IF NOT APPLICABLE, PUT N/A
(Signature of Declarant) (Signature of Co-Declarant/Spouse)
15. PLEASE PROVIDE THE FOLLOWING DETAILS
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.
16. Please leave this BLANK
_______________________________________
(Person Administering Oath)
Page 2 of ___ <---- 17. Page of how many?

2015 Saln Form - Guide

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2015 Saln Form - Guide

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Revised as of January 2015

Per CSC Resolution No. 1500088

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

NAME DATE OF BIRTH AGE

5. PLEASE FILL UP THE BLANKS, IF NOT APPLICABLE WRITE N/A

ASSETS, LIABILITIES AND NETWORTH

DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION

DESCRIPTION YEAR ACQUIRED ACQUISITION

TOTAL ASSETS (a+b):

Page 1 of ___ <---- 8. Page of how many ?

NATURE NAME OF CREDITORS OUTSTANDING BALANCE

TOTAL LIABILITIES: 0.00

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

RELATIVES IN THE GOVERNMENT SERVICE

Page 2 of ___ <---- 17. Page of how many?

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