Scribd
Upload
49 views

SALN Form Blank

This document is a sworn statement of assets, liabilities, and net worth that must be filed by all public officials and employees in the Philippines according to law. It includes sections for the declarant's personal details and position, assets and their values, liabilities, net worth, business interests, relatives in government, and signatures to certify the truth and accuracy of the statement. The declarant listed is a secondary school teacher who files this statement individually, declaring no assets or financial connections beyond what is stated in the form.

Uploaded by

Janine Ompoy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
49 views

SALN Form Blank

This document is a sworn statement of assets, liabilities, and net worth that must be filed by all public officials and employees in the Philippines according to law. It includes sections for the declarant's personal details and position, assets and their values, liabilities, net worth, business interests, relatives in government, and signatures to certify the truth and accuracy of the statement. The declarant listed is a secondary school teacher who files this statement individually, declaring no assets or financial connections beyond what is stated in the form.

Uploaded by

Janine Ompoy
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 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 _____31 December 2022________
(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: Versoza, Ahinoam E. POSITION: Secondary School Teacher I


(Family Name) (First Name) (M.I.) AGENCY/OFFICE: DepEd/Zambo. City High School (Main)
ADDRESS: B. Agustin Drive, Divisoria, Zamboanga City OFFICE ADDRESS: Don Alfaro St., Tetuan,
Zamboanga City

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

Subtotal:
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 2
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 .

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF


ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION
N/A

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: February 11, 2022

(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.

TRICIA A. CORRALES
Planning Officer III
OIC, Office of the Administrative Service
(Person Administering Oath)
Page 2 of 2

You might also like