Saln-form.xls 6mv5g

Revised as of January 2015 Per CSC Resolution No. 15000 Promulgated on January 23, 2

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of DECEMBER 31, 2016 (Required by R.A. 6713) Note: Husband and wife who are both public officials and employees may file the required statements tly or separately.

q t Filing

q Separate Filing

q Not Applicable

DECLARANT:

POSITION: (Family Name)

(First Name)

AGENCY/OFFICE:

(M.I.)

ADDRESS:

OFFICE ADDRESS:

SPOUSE:

POSITION: (Family Name)

(First Name)

AGENCY/OFFICE:

(M.I.)

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 (e.g. lot, house and lot, condominium and improvements)

CURRENT

KIND EXACT LOCATION

(e.g. residential, commercial, industrial, agricultural and mixed use)

ASSESSED FAIR MARKET VALUE VALUE (As found in the Tax Declaration of Real Property

ACQUISITION ACQUISITION COST YEAR

MODE

SubTotal b. PERSONAL PROPERTIES* DESCRIPTION

Subtotal: _____________

YEAR ACQUIRED

Subtotal : __________________ __ TOTAL ASSETS (a+b):

-

ACQUISITION COST/AMOUNT

-

2.  LIABILITIES* NATURE

NAME OF CREDITORS

TOTAL LIABILITIES: ________________ NET WORTH : Total Assets less Total Liabilities = * Additional sheet/s may be used, if necessary.

OUTSTANDING BALANCE

-

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of DECEMBER 31, 2015 (Required by R.A. 6713) Additional Sheet Note: Husband and wife who are both public officials and employees may file the required statements tly or separately.

q t Filing

q Separate Filing

q Not Applicable

DECLARANT:

POSITION: (Family Name)

(First Name)

AGENCY/OF FICE:

(M.I.)

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. DESCRIPTION (e.g. lot, house and lot, condominium and Improvement)

Real Properties* KIND (e.g. residential, commercial, industrial, agricultural and mixed use)

EXACT LOCATION

ASSESSED VALUE

CURRENT FAIR MARKET VALUE

ACQUISITION ACQUISITION COST

(As found in the Tax Declaration of Real Property)

YEAR

MODE

Sub Total

-

b. Personal Properties* DESCRIPTION

YEAR ACQUIRED

ACQUISITION COST/AMOUNT

n/a

n/a

n/a

-

Subtotal TOTAL ASSETS (a+b):

-

2.    LIABILITIES* NATURE

n/a

NAME OF CREDITORS

n/a

OUTSTANDING BALANCE

n/a

NET WORTH: Total Total AssetsLiabilities Less Total Liabilities

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (of Declarant /Declarant’s spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarant’s Household) q 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

n/a

n/a

n/a

n/a

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