SALN 1994 FORM (2)
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SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL CONNECTIONS AS OF DECEMBER 31, 2009 NAME (Surname First Name Middle Name) Position Title Incom e Office Address Spouse Name (Surname First Name Middle Name) Position Title Office Address Unmarried Children Below 18 years of age (Use additional sheets if necessary) Name of Child Date of Birth A. ASSETS AND LIABILITIES 1. Assets a. Real Properties (Use additional sheets if necessary ) Kind & Location Year Acquire d Mode of Acquisition Assessed Value Current Fair Market Value ACQUISITION COST Buildings & Others Improv e ments TOTAL b. Personal and Other Properties (Use additional sheets if necessary) Kind Year Acquired Acquisition Cost TOTAL TOTAL ASSETS: 2. Liabilities (Loans, Mortgages, etc.) [Use additional sheets if necessary] Nature Amount TOTAL LIABILITIES
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Transcript of SALN 1994 FORM (2)
8/7/2019 SALN 1994 FORM (2)
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SWORN STATEMENT OF ASSETS, LIABILITIES AND NETWORTH
DISCLOSURE OF BUSINESS INTEREST AND FINANCIAL
CONNECTIONSAS OF DECEMBER 31, 2009
NAME(Surname First Name Middle Name)
Position Title Income
OfficeAddress
Spouse Name(Surname First Name Middle Name)
Position TitleOfficeAddress
Unmarried Children Below 18 years of age (Use additional sheets if necessary)Name of Child Date of Birth
A. ASSETS AND LIABILITIES
1. Assets
a. Real Properties (Use additional sheets if necessary)
Kind &Location
YearAcquire
d
Mode of Acquisition
AssessedValue
Current FairMarket Value
ACQUISITION COSTBuildings& Others
Improve
ments
TOTAL
b. Personal and Other Properties (Use additional sheets if necessary)
Kind Year Acquired Acquisition Cost
TOTAL
TOTAL ASSETS:
2. Liabilities (Loans, Mortgages, etc.) [Use additional sheets if necessary]Nature Amount
TOTAL LIABILITIES
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NETWORTH (Total Assets (1a+1b) Less Total Liabilities:
B. DISCLOSURE OF BUSINESS INTERESTS AND FINANCIAL
CONNECTIONS
Do you have interests and/or financial connections including those of yourspouse and unmarried children below 18 years of age living with you in your
household? Yes No If Yes, giveparticulars.
NameName of Firm or
CompanyAddress of Firm or
Company
Nature of BusinessInterests and/or
FinancialConnections
Date of Acquisition orConnection
C. IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE
To the best of your knowledge, are you related within the fourth degree of consanguinity or affinity to anyone working in the government? Yes
No. If Yes, giveparticulars.
Name Position Title Relationship
Name & Address of Office
I HEREBY CERTIFY to the best of my knowledge and information that theseare true statement of my assets, liabilities, net worth, business interests and
financial connections including those of my spouse and unmarried children below 18years of age and names of my relatives in the government as of 31 December 2009as required by and in accordance with RA 6713.
I HEREBY AUTHORIZE the Ombudsman or his duly authorized representativeto obtain and secure from all appropriate government agencies including theBureau of Internal Revenue, such documents that my assets, liabilities, net worth,business interests and financial connections including those of my spouse andunmarried children below 18 years of age living with me in my household coveringprevious years to include the first year I assumed office in the government.
Date: ,
Signature of Spouse Signature of Employee
TIN : TIN :Comm. Tax Cert.No.
: Comm. Tax Cert.No.
:
Issued at : Issued at :Date Issued : Date Issued :
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SUBSCRIBED AND SWORN TO before me this _____ day of _____________, __________, affiants exhibiting to me their Community TaxCertificates bearing the number indicated hereinabove.
PERSON ADMINISTERING
OATH
