2015 Saln Form

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 2015
(Required by R.A. 6713)
Note: Husband and wife who are both public officials and employees may file the required statements jointly or separately.
Joint Filing
MENDOZA,
DECLARANT
FLORDELIZA
Separate Filing
A..
Not Applicable
TEACHER II
POSITION:
:
(Family Name)
(First Name)
(M.I.)
AGENCY/OFFICE:
DEPED BATANGAS
ADDRESS:
STA.TERESITA,
STO.TOMAS,
OFFICE ADDRESS:
PROVINCIAL SPORTS COMPLEX
BATANGAS
BOLBOK, BATANGAS CITY
MENDOZA,
SPOUSE:
EDGARDO
(Family Name)
(First Name)
N.
(M.I.)
POSITION:
N/A
AGENCY/OFFICE:
N/A
OFFICE ADDRESS:
N/A
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANTS HOUSEHOLD
NAME
DATE OF BIRTH
CAMILLE A. MENDOZA
JOHN AARON A. MENDOZA
AGE
06/21/1998
05/22/2010
17
5
ASSETS, LIABILITIES AND NETWORTH

(Including those of the spouse and unmarried children below eighteen (18)
years of age living in declarants household)
1. ASSETS
a.
Real Properties*
DESCRIPTION
KIND
EXACT
ASSESSED
CURRENT FAIR
(e.g. lot, house and

lot, condominium
and improvements)
(e.g. residential,
commercial, industrial,
agricultural and mixed
use)
LOCATION
VALUE
MARKET VALUE
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
ACQUISITION
ACQUISITION
COST
(As found in the Tax Declaration of

Real Property)
YEAR
MODE
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
Subtotal:
b. Personal Properties*
DESCRIPTION
YEAR ACQUIRED
N/A
ACQUISITION
COST/AMOUNT
APPLIANCES
FURNITURE
GADGETS
2001-2004
2004,2013
2015
Page 1 of ___
60,000.00
27,000.00
15,000.00
Subtotal : 102,000.00
TOTAL ASSETS (a+b):
* Additional sheet/s may be used, if necessary.
Page 2 of ___
102,000.00
2. LIABILITIES*
NATURE
Salary Loan
Salary Loan
Emergency Loan
NAME OF CREDITORS
OUTSTANDING BALANCE
GSIS
MTMAS
PAG IBIG
356,000.00
204,000.00
30,000.00
TOTAL LIABILITIES:
590,000.00
NET WORTH : Total Assets less Total Liabilities =
488,000.00
* Additional sheet/s may be used, if necessary.
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

(of Declarant /Declarants spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarants Household)
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
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
RELATIVES IN THE GOVERNMENT SERVICE

(Within the Fourth Degree of Consanguinity or Affinity. Include also Bilas, Balae and Inso)
I/We do not know of any relative/s in the government service)

NAME OF RELATIVE
RELATIONSHIP
POSITION
NAME OF AGENCY/OFFICE AND ADDRESS
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
N/A
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 aboveenumerated are names of my relatives in the government within the fourth civil degree of consanguinity or
affinity.
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)
Government Issued ID:
ID No.:
Date Issued:
(Signature of Co-Declarant/Spouse)
PRC/GSIS
022375/ 2002987594
05/14/2015
Government Issued ID:

ID No.:
Date Issued:
SUBSCRIBED AND SWORN to before me this
day of
Page 3 of ___
VOTERS ID
1028-0266A-F2662ENM10001-2
1997
, affiant exhibiting to me the above-stated
government issued identification card.

_______________________________________
(Person Administering Oath)
Page 4 of ___

2015 Saln Form

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2015 Saln Form

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Revised as of January 2015

Per CSC Resolution No. 1500088

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

BOLBOK, BATANGAS CITY

ASSETS, LIABILITIES AND NETWORTH

(e.g. lot, house and

(As found in the Tax Declaration of

NET WORTH : Total Assets less Total Liabilities =

* Additional sheet/s may be used, if necessary.

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS

I/We do not have any business interest or financial connection.

RELATIVES IN THE GOVERNMENT SERVICE

I/We do not know of any relative/s in the government service)

NAME OF AGENCY/OFFICE AND ADDRESS

Government Issued ID:

SUBSCRIBED AND SWORN to before me this

, affiant exhibiting to me the above-stated

government issued identification card.

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