Scribd
Upload
9 views

SALN FORM

The document is a Sworn Statement of Assets, Liabilities, and Net Worth required by R.A. 6713, to be filed by public officials and employees as of December 2023. It includes sections for personal information, asset and liability details, business interests, and relatives in government service. The declarant certifies the accuracy of the information and authorizes the Ombudsman to verify it with relevant agencies.

Uploaded by

Barangay A Tumamak
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
9 views

SALN FORM

The document is a Sworn Statement of Assets, Liabilities, and Net Worth required by R.A. 6713, to be filed by public officials and employees as of December 2023. It includes sections for personal information, asset and liability details, business interests, and relatives in government service. The declarant certifies the accuracy of the information and authorizes the Ombudsman to verify it with relevant agencies.

Uploaded by

Barangay A Tumamak
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/ 3

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, 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*
DESCRIPTIO KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION
N (e.g. residential, LOCATION VALUE MARKET COST
commercial,
(e.g. lot, house and industrial, agricultural VALUE
lot, condominium and mixed use) (As found in the Tax Declaration of
and improvements)
Real Property)
YEAR MODE

Subtotal:
b. Personal Properties*

DESCRIPTION YEAR ACQUIRED ACQUISITION


COST/AMOUNT

Page 1 of ___
Subtotal : Ᵽ
TOTAL ASSETS (a+b): Ᵽ
* Additional sheet/s may be used, if necessary.

2. LIABILITIES*

NATURE NAME OF CREDITORS OUTSTANDING


BALANCE

TOTAL LIABILITIES: Ᵽ
NET WORTH : Total Assets less Total Liabilities = Ᵽ
* 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 BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF


ENTITY/BUSINESS INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
ENTERPRISE CONNECTION

NONE

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.
Page 2 of ___
ENGR. CARLOS G. VELOSO
(Person Administering Oath)
MUNICIPAL MAYOR
VILLABA, LEYTE

Page 3 of ___

You might also like