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Hrep Saln Form-11
Hrep Saln Form-11
Note: Husband and wife who are both public officials/employees may file their SALN jointly or separately. The declarant who is single, widowed, divorced or annulled or married to a private person shall tick off the box marked below as “Not
Applicable”.
OFFICE ADDRESS:
OFFICE ADDRESS:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN THE DECLARANT’S HOUSEHOLD
NAME DATE OF BIRTH AGE
1. ASSETS
1
a. Real Properties
DESCRIPTION KIND EXACT ASSESSED VALUE CURRENT FAIR MARKET ACQUISITION ACQUISITION COST
(e.g. Lot, House and Lot, (e.g. Residential, Commercial, Industrial, LOCATION VALUE
Condominium and Improvement) Agricultural and Mixed Use)
As found in the Latest Tax Declaration As found in the Latest BIR Zonal Value YEAR MODE
Total Value of Real Properties (Including those declared in the Additional Sheet, if any):
2
b. Personal Properties
YEAR MODE
Total Value of Personal Properties (Including those declared in the Additional Sheet, if any):
3
2. LIABILITIES
4
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(Business interests and financial connections of the spouse and unmarried children, if any, should be declared in the Separate Sheet/s)
NAME OF BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS INTEREST OR FINANCIAL DATE OF ACQUISITION OF INTEREST OR
CONNECTION CONNECTION
ENTITY/ENTERPRISE
5
RELATIVES IN THE GOVERNMENT SERVICE
1 Additional Sheet/s may be used, if necessary. In case of joint filing, the list should include the exclusive properties of the spouse.
2 Additional Sheet/s may be used, if necessary. In case of joint filing, the list should include the exclusive properties of the spouse.
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(Within the Fourth Degree of Consanguinity or Affinity, including Bilas, Balae and Inso)
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
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)
ID No.: ID No.:
SUBSCRIBED AND SWORN to before me this day of , affiant exhibiting to me the above-stated government issued identification card.
_______________________________________
ADDITIONAL SHEET
Note: This Additional Sheet may be used to declare additional list of declarant’s assets, liabilities and financial interests and financial connections, including those of the declarant’s spouse in case of joint filing.
DECLARANT: POSITION:
DESCRIPTION KIND EXACT ASSESSED VALUE CURRENT FAIR MARKET ACQUISITION ACQUISITION COST
(e.g. lot, house and lot, (e.g. residential, commercial, industrial, LOCATION VALUE
condominium and improvement) agricultural and mixed use)
As found in the Latest Tax Declaration As found in the Latest BIR Zonal Value YEAR MODE
NAME OF ENTITY/BUSINESS ENTERPRISE BUSINESS ADDRESS NATURE OF BUSINESS INTEREST &/OR FINANCIAL DATE OF ACQUISITION OF INTEREST OR
CONNECTION CONNECTION
SEPARATE SHEET
Note: This Separate Sheet shall be used in declaring (1) exclusive properties of the declarant’s spouse except in case of joint filing; (2) properties owned by the declarant’s unmarried children below 18 years of age living in the
declarant’s household; and (3) their business interests and financial connections.
DECLARANT: POSITION:
A. ASSETS
DESCRIPTION KIND EXACT ASSESSED VALUE CURRENT FAIR MARKET ACQUISITION ACQUISITION COST
(e.g. lot, house and lot, (e.g. residential, commercial, industrial, LOCATION VALUE
condominium and improvement) agricultural and mixed use)
As found in the Latest Tax Declaration As found in the Latest BIR Zonal Value YEAR MODE
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Total Value of Real Properties of the Declarant’s Spouse and Unmarried Children:
Total Value of Personal Properties of the Declarant’s Spouse and Unmarried Children:
B. LIABILITIES (Separate)
NAME OF ENTITY/BUSINESS ENTERPRISE BUSINESS ADDRESS NATURE OF BUSINESS INTEREST &/OR FINANCIAL DATE OF ACQUISITION OF INTEREST OR
CONNECTION CONNECTION
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