Saln Blank
Saln Blank
Saln Blank
Note: Husband and wife who are both public officials and employees may file the required statements jointly or separately.
Joint Filing Separate Filing Not Applicable
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NONE
Subtotal:
b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION COST/AMOUNT
Subtotal : 46,000
TOTAL ASSETS (a+b): 46,000
2 . LIABILITIES*
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
NONE
TOTAL LIABILITIES:
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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
NONE
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 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: ________________________
SUBSCRIBED AND SWORN to before me this ______day of _______, affiant exhibiting to me the above-stated
government issued identification card.
________________________
(Person Administering Oath)
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