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SALN Revised 2013

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH


As of ________________________________ (Sample additional sheet/s for the exclusive properties of the declarants spouse and unmarried children below eighteen (18) years of age living in declarants household)
NAME: (Family Name) (First Name) (M.I.) POSITION: AGENCY/OFFICE:

ASSETS, LIABILITIES AND NET WORTH 1. ASSETS a. Real Proper !e"


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

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

LOCATION

ASSESSED $AL%E

C%RRENT FAIR MAR#ET $AL%E

AC&%ISITION YEAR MODE

AC&%ISITION COST

(As found in the ax !eclaration of "eal #roperty)

'. Per"o(al Proper !e"


DESCRIPTION YEAR AC&%IRED AC&%ISITION COST/AMO%NT

). LIABILITIES
NAT%RE NAME OF CREDITORS O%TSTANDING BALANCE

B%SINESS INTERESTS AND FINANCIAL CONNECTIONS

NAME OF ENTITY/B%SINESS ENTERPRISE

B%SINESS ADDRESS

NAT%RE OF B%SINESS INTEREST */OR FINANCIAL CONNECTION

DATE OF AC&%ISITION OF INTEREST OR CONNECTION

Page __ of ___

SALN Revised 2013

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH


As of ________________________________ (Sample additional sheet/s for the declarant)
NAME: (Family Name) (First Name) (M.I.) POSITION: AGENCY/OFFICE:

ASSETS, LIABILITIES AND NET WORTH 1. ASSETS a. Real Proper !e"


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

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

LOCATION

ASSESSED $AL%E

C%RRENT FAIR MAR#ET $AL%E

AC&%ISITION YEAR MODE

AC&%ISITION COST

(As found in the ax !eclaration of "eal #roperty)

S+' o al : '. Per"o(al Proper !e"


DESCRIPTION YEAR AC&%IRED AC&%ISITION COST/AMO%NT

S+' o al : TOTAL ASSETS ,a-'.: ). LIABILITIES


NAT%RE NAME OF CREDITORS O%TSTANDING BALANCE

TOTAL LIABILITIES:

B%SINESS INTERESTS AND FINANCIAL CONNECTIONS

NAME OF ENTITY/B%SINESS ENTERPRISE

B%SINESS ADDRESS

NAT%RE OF B%SINESS INTEREST */OR FINANCIAL CONNECTION

DATE OF AC&%ISITION OF INTEREST OR CONNECTION

Page __ of ___

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