Saln 2015 Form.pdf
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- Words: 282
- Pages: 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 (Additional sheet/s for the exclusive properties of the declarant’s spouse and unmarried children Below eighteen (18) years of age living in declarant’s household) NAME:
(Family Name)
(First Name)
POSITION: AGENCY/OFFICE:
(M.I.)
ASSETS, LIABILITIES AND NETWORTH
1. ASSETS a. Real Properties DESCRIPTION (e.g. lot, house and lot, condominium and improvements)
KIND
(e.g. residential, commercial, industrial, agricultural and mixed use)
ASSESSED VALUE
EXACT LOCATION
CURRENT FAIR MARKET VALUE
(As found in the Tax Declaration of Real Property)
ACQUISITION YEAR
ACQUISITION COST
MODE
b. Personal Properties DESCRIPTION
YEAR ACQUIRED
ACQUISITION COST/AMOUNT
2. LIABILITIES NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
NATURE OF BUSINESS INTEREST&/ OR FINANCIAL CONNECTION
Page 1 of 2
DATE OF ACQUISITION OF INTEREST OR CONNECTION
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
(Additional sheet/s for the declarant) NAME:
(Family Name)
(First Name)
POSITION: AGENCY/OFFICE:
(M.I.)
ASSETS, LIABILITIES AND NETWORTH
1. ASSETS a. Real Properties DESCRIPTION (e.g. lot, house and lot, condominium and improvements)
KIND
(e.g. residential, commercial, industrial, agricultural and mixed use)
ASSESSED VALUE
EXACT LOCATION
CURRENT FAIR MARKET VALUE
(As found in the Tax Declaration of Real Property)
ACQUISITION YEAR
ACQUISITION COST
MODE
b. Personal Properties DESCRIPTION
YEAR ACQUIRED
ACQUISITION COST/AMOUNT
2. LIABILITIES NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
NATURE OF BUSINESS INTEREST&/ OR FINANCIAL CONNECTION
Page 2 of 2
DATE OF ACQUISITION OF INTEREST OR CONNECTION
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH As of (Additional sheet/s for the exclusive properties of the declarant’s spouse and unmarried children Below eighteen (18) years of age living in declarant’s household) NAME:
(Family Name)
(First Name)
POSITION: AGENCY/OFFICE:
(M.I.)
ASSETS, LIABILITIES AND NETWORTH
1. ASSETS a. Real Properties DESCRIPTION (e.g. lot, house and lot, condominium and improvements)
KIND
(e.g. residential, commercial, industrial, agricultural and mixed use)
ASSESSED VALUE
EXACT LOCATION
CURRENT FAIR MARKET VALUE
(As found in the Tax Declaration of Real Property)
ACQUISITION YEAR
ACQUISITION COST
MODE
b. Personal Properties DESCRIPTION
YEAR ACQUIRED
ACQUISITION COST/AMOUNT
2. LIABILITIES NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
NATURE OF BUSINESS INTEREST&/ OR FINANCIAL CONNECTION
Page 1 of 2
DATE OF ACQUISITION OF INTEREST OR CONNECTION
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
(Additional sheet/s for the declarant) NAME:
(Family Name)
(First Name)
POSITION: AGENCY/OFFICE:
(M.I.)
ASSETS, LIABILITIES AND NETWORTH
1. ASSETS a. Real Properties DESCRIPTION (e.g. lot, house and lot, condominium and improvements)
KIND
(e.g. residential, commercial, industrial, agricultural and mixed use)
ASSESSED VALUE
EXACT LOCATION
CURRENT FAIR MARKET VALUE
(As found in the Tax Declaration of Real Property)
ACQUISITION YEAR
ACQUISITION COST
MODE
b. Personal Properties DESCRIPTION
YEAR ACQUIRED
ACQUISITION COST/AMOUNT
2. LIABILITIES NATURE
NAME OF CREDITORS
OUTSTANDING BALANCE
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS NAME OF ENTITY/BUSINESS ENTERPRISE
BUSINESS ADDRESS
NATURE OF BUSINESS INTEREST&/ OR FINANCIAL CONNECTION
Page 2 of 2
DATE OF ACQUISITION OF INTEREST OR CONNECTION
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