revised saln form(feb. 1, 2012)

REVISED REVISED SALN FORMSALN FORM

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Legal BasisLegal Basis::

Section 8 of Republic Act 6713Section 8 of Republic Act 6713 or or the the Code of Conduct and Ethical Code of Conduct and Ethical Standards for Public Officials and Standards for Public Officials and EmployeesEmployees..

Section 7 of RA 3019Section 7 of RA 3019 or the or the Anti-Anti-Graft and Corrupt Practices ActGraft and Corrupt Practices Act. .

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STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

AND DISCLOSURE OF BUSINESS INTERESTS, FINANCIAL CONNECTIONS

AND RELATIVE/S IN THE GOVERNMENT SERVICE

As of December 31, ________ (Required by R.A. Nos. 3019 and 6713)

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Pursuant to R.A. Nos. 6713 and 3019, declarant is Pursuant to R.A. Nos. 6713 and 3019, declarant is required to declare in the Revised SALN Form the required to declare in the Revised SALN Form the following: following: (1) Assets, Liabilities (R.A. 6713 and 3019);(1) Assets, Liabilities (R.A. 6713 and 3019);(2) Net Worth (R.A. 6713); (2) Net Worth (R.A. 6713); (3) Business Interests and Financial Connections; (3) Business Interests and Financial Connections; (R.A. 6713); (R.A. 6713); (4) Relatives in the Government (R.A. 6713);(4) Relatives in the Government (R.A. 6713);(5) Amount and Sources of Gross Income (R.A. (5) Amount and Sources of Gross Income (R.A. 3019); 3019); (6) Amount of Personal and Family Expenses;(6) Amount of Personal and Family Expenses; (R.A. 3019); (R.A. 3019);and and (7) Amount of Income Taxes Paid (R.A. 3019). (7) Amount of Income Taxes Paid (R.A. 3019).

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Who files the SALN form?Who files the SALN form?

All public officials and employeesAll public officials and employees

(except those who serve in (except those who serve in honorary honorary capacity, laborers and casual or capacity, laborers and casual or

temporary workerstemporary workers))

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Husband and Wife who are Husband and Wife who are bothboth public officials or employees public officials or employees maymay

file the required statementsfile the required statements

jointlyjointly or or separatelyseparately

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(Note: Husband and Wife who are both public officials or employees may file the required

statements jointly or separately.)

Jointly filed. Separately filed.

88

Under the Personal Circumstances, Under the Personal Circumstances, declarant is required to state the declarant is required to state the following:following:(a) (a) surname, first name, middle surname, first name, middle initialinitial;;(b) (b) addressaddress;;(c) (c) positionposition;;(d) (d) officeoffice;;(e) (e) office addressoffice address..

99

I am married. I am not married

If marriedIf married, he/she is required to state the following:, he/she is required to state the following:

(a) (a) spouse’s surname, first name, middle initialspouse’s surname, first name, middle initial;;(b) (b) positionposition;;(c) (c) officeoffice;;(d) (d) office addressoffice address..

Declarant is required to indicate whether or not he/she is Declarant is required to indicate whether or not he/she is married by married by ticking offticking off the proper box. the proper box.

1010

If the declarant has unmarried children below 18 If the declarant has unmarried children below 18 years of age living in his/her household, he/she has to years of age living in his/her household, he/she has to state their state their name/sname/s and and date of birthdate of birth..

If without unmarried children below 18 years of age If without unmarried children below 18 years of age living in his/her household, declarant is required to living in his/her household, declarant is required to tick offtick off the proper box. the proper box.

I have no children below 18 years of age living in my household.

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Under Under AssetsAssets, there are two (2) parts:, there are two (2) parts:

(a) (a) Real Property/ies – Real Property/ies – refer/s to those of refer/s to those of the declarant and his/her spouse and the declarant and his/her spouse and unmarried children below 18 years of unmarried children below 18 years of age living in his/her household.age living in his/her household.

(b) (b) Personal Property/ies- Personal Property/ies- refer/s to those refer/s to those of the declarant and his/her spouse and of the declarant and his/her spouse and unmarried children below 18 years of unmarried children below 18 years of age living in his/her household.age living in his/her household.

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TANGIBLETANGIBLE ACQUISITIONACQUISITION

MODE YEAR MODE YEAR

ACQUISITION COST*ACQUISITION COST*

INTANGIBLEINTANGIBLE

KindKind(Res./Comm./(Res./Comm./

Agri., etc.)Agri., etc.)

Nature of Nature of

PropertyProperty(Paraphernal,(Paraphernal,

conjugal orconjugal or

community)community)

LOCATIONLOCATION ACQUISITIONACQUISITION

MODE YEARMODE YEAR

ASSESSEDASSESSED

VALUEVALUE

FAIRFAIR

MARKETMARKET

VALUEVALUE


Land, Improvement/sLand, Improvement/s

Building,Building,

othersothers

A. REAL PROPERTY/IES (use additional sheet/s, if necessary)

B. PERSONAL PROPERTY/IES AND OTHER ASSETS (use additional sheet/s, if necessary)

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The following are required under Real The following are required under Real Property/ies:Property/ies:(a) (a) Kind (Kind (residential, commercial, residential, commercial, agricultural, etcagricultural, etc.);.);(b) (b) Nature of Property (Nature of Property (paraphernal, paraphernal, conjugal or communityconjugal or community););(c) (c) Location;Location;(d) (d) Acquisition Mode and Year;Acquisition Mode and Year;(e) (e) Assessed Value;Assessed Value; (f ) (f ) Fair Market Value;Fair Market Value;(g) (g) Acquisition Cost of Land, Building, Acquisition Cost of Land, Building, others, and the Improvements thereonothers, and the Improvements thereon..

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Nature of Nature of





MODE YEARMODE YEAR

ASSESSEDASSESSED

VALUEVALUE

FAIRFAIR

MARKETMARKET

VALUEVALUE



Building,Building,

othersothers

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The following are required under Personal Property/ies and Other Assets:

(a) Tangible; (b) Intangible; (c) Acquisition Mode and Year; (d) Acquisition Cost.

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MODE YEAR MODE YEAR



1717

Other AssetsOther Assets would refer to would refer to investments or intangible assets investments or intangible assets such as such as stocks/shares and the like, stocks/shares and the like, cash on hand and in the bank, cash on hand and in the bank, denominated in foreign currency denominated in foreign currency shall be converted into the shall be converted into the corresponding Philippine currency corresponding Philippine currency equivalent, at the rate of exchange equivalent, at the rate of exchange prevailing as of December 31 of the prevailing as of December 31 of the preceding calendar year.preceding calendar year.

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Reminders:Reminders:

(a) For computation purposes (Real and (a) For computation purposes (Real and Personal Properties), use Personal Properties), use Acquisition CostAcquisition Cost..

(b) Properties of unmarried children below 18 (b) Properties of unmarried children below 18 years of age living in his/her household shall years of age living in his/her household shall be be excludedexcluded in the computation. in the computation.

(c) Paraphernal/exclusive properties of spouse, (c) Paraphernal/exclusive properties of spouse, in case of in case of separate filingseparate filing, shall also be , shall also be excludedexcluded in the computation. in the computation.

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MODE YEAR MODE YEAR


Toyota CorollaToyota Corolla Purchase 2004 Purchase 2004 250,000.00250,000.00


Educational PlanEducational Plan Purchase on installment 2006Purchase on installment 2006 500,000.00500,000.00



Nature of Nature of





MODE YEARMODE YEAR

ASSESSEDASSESSED

VALUEVALUE

FAIRFAIR

MARKETMARKET

VALUEVALUE



Building,Building,

othersothers

ResidentialResidential CommunityCommunity RizalRizal Purchase 2009Purchase 2009 1.8 M1.8 M 1.9 M1.9 M 1.5 M 250,000.001.5 M 250,000.00

CommercialCommercial ParaphernalParaphernal PampangaPampanga Donation 2006Donation 2006 2 M2 M 2.4 M2.4 M 2 M 100,000.002 M 100,000.00



Reminders:Reminders:Where the declarant and his/her spouse are both government officials/employees, Where the declarant and his/her spouse are both government officials/employees, all their properties are all their properties are includedincluded in the declaration. in the declaration.

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MODE YEAR MODE YEAR







Nature of Nature of





MODE YEARMODE YEAR

ASSESSEDASSESSED

VALUEVALUE

FAIRFAIR

MARKETMARKET

VALUEVALUE



Building,Building,

othersothers





Where the declarant’s spouse is Where the declarant’s spouse is notnot a government official/employee, a government official/employee, the spouse’ properties are also the spouse’ properties are also includedincluded in the declaration. in the declaration.

2121


MODE YEAR MODE YEAR





750,000.00750,000.00



Nature of Nature of





MODE YEARMODE YEAR

ASSESSEDASSESSED

VALUEVALUE

FAIRFAIR

MARKETMARKET

VALUEVALUE



Building,Building,

othersothers



3.5 M 350,000.003.5 M 350,000.00



In case of In case of joint filingjoint filing, the assets of the declarant’s spouse are , the assets of the declarant’s spouse are includedincluded in the computation of total assets. in the computation of total assets.

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MODE YEAR MODE YEAR


Toyota CorollaToyota Corolla Inheritance 2004 Inheritance 2004 250,000.00250,000.00



500,000.00500,000.00



Nature of Nature of





MODE YEARMODE YEAR

ASSESSEDASSESSED

VALUEVALUE

FAIRFAIR

MARKETMARKET

VALUEVALUE



Building,Building,

othersothers



1.5M 250,000.001.5M 250,000.00



In case of In case of separate filingseparate filing, the paraphernal/exclusive properties of the , the paraphernal/exclusive properties of the declarant’s spouse are declarant’s spouse are excludedexcluded in the computation of total assets. in the computation of total assets.

2323


MODE YEAR MODE YEAR


Toyota CorollaToyota Corolla Inheritance 2004 Inheritance 2004 250,000.00250,000.00



500,000.00500,000.00



Nature of Nature of





MODE YEARMODE YEAR

ASSESSEDASSESSED

VALUEVALUE

FAIRFAIR

MARKETMARKET

VALUEVALUE



Building,Building,

othersothers



1.5M 250,000.001.5M 250,000.00



The assets of the declarant’s spouse (The assets of the declarant’s spouse (not in government servicenot in government service) are ) are excludedexcluded in the computation of total assets. in the computation of total assets.

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In determining the In determining the Total AssetsTotal Assets, add , add the sum total (based on acquisition the sum total (based on acquisition cost) of both Real and Personal cost) of both Real and Personal Properties.Properties.

TOTAL ASSETS (A+B)=_______________

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Under Liabilities, the declarant and Under Liabilities, the declarant and his/her spouse and unmarried children his/her spouse and unmarried children below 18 years of age living in his/her below 18 years of age living in his/her household shall declare the following:household shall declare the following:

(a) (a) Nature of LiabilityNature of Liability (personal, salary, (personal, salary, calamity loan, etc);calamity loan, etc);

(b) (b) Name of Creditor/sName of Creditor/s;;

(c) (c) Outstanding BalanceOutstanding Balance (principal loan (principal loan including interests)including interests)

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II. Liabilities (including that of declarant’s spouse and unmarried children below 18 years of age living in his/her household)

NATURENATURE NAME OF CREDITOR/SNAME OF CREDITOR/S *OUTSTANDING BALANCE*OUTSTANDING BALANCE

TOTAL:_____________________

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In the computation of the In the computation of the Outstanding BalanceOutstanding Balance, those of the , those of the spouse and unmarried children below spouse and unmarried children below 18 years of age living in his/her 18 years of age living in his/her household shall be household shall be excluded excluded exceptexcept in case ofin case of joint filing, joint filing, in which case, in which case, the outstanding obligation of the the outstanding obligation of the declarant’s spouse shall also be declarant’s spouse shall also be included included in the said computation.in the said computation.

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The declarant’s The declarant’s Total Net WorthTotal Net Worth, , and that of his/her spouse, in case ofand that of his/her spouse, in case of joint filingjoint filing, shall be the difference , shall be the difference between the Total Assets (real and between the Total Assets (real and personal properties) and the Total personal properties) and the Total Liabilities.Liabilities.

TOTAL NET WORTH:_____________

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a.)a.) In case of In case of joint filingjoint filing, the declarant and , the declarant and his/her spouse shall declare the amounts and sources of all his/her spouse shall declare the amounts and sources of all their Gross Income, whether derived from practice of their Gross Income, whether derived from practice of profession, business, and the like, for the preceding profession, business, and the like, for the preceding calendar year. (R.A. 3019)calendar year. (R.A. 3019)

AMOUNT AND SOURCES OF GROSS INCOMEAMOUNT AND SOURCES OF GROSS INCOME(ALL amounts received from ALL sources for the preceding (ALL amounts received from ALL sources for the preceding

calendar year)calendar year)

(use additional sheet/s, if necessary)(use additional sheet/s, if necessary)

TOTAL:___________________TOTAL:___________________

NATURENATURE

(salary/income, (salary/income, business, etc.)business, etc.)

SOURCESSOURCES AMOUNTAMOUNT

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b) In case of b) In case of joint filingjoint filing, the declarant and , the declarant and his/her spouse shall declare the estimated his/her spouse shall declare the estimated amounts of their personal and family expenses, amounts of their personal and family expenses, for the preceding calendar year. (R.A. 3019)for the preceding calendar year. (R.A. 3019)

AMOUNT OF PERSONAL AND FAMILY EXPENSES(for the preceding calendar year)

(use additional sheet/s, if necessary)

TOTAL:_____________________

PERSONAL PERSONAL EXPENSESEXPENSES

ESTIMATED ESTIMATED

AMOUNTAMOUNT

FAMILY FAMILY EXPENSESEXPENSES

ESTIMATEDESTIMATED

AMOUNTAMOUNTFood allowanceFood allowance 200X365 P73,000.00200X365 P73,000.00 Annual WaterAnnual Water 6,000.006,000.00

3131

c) In case of c) In case of joint filingjoint filing, the declarant and , the declarant and his/her spouse shall declare all the taxes paid his/her spouse shall declare all the taxes paid for the preceding calendar year, whether taxes for the preceding calendar year, whether taxes imposed on income or business. (R.A. 3019)imposed on income or business. (R.A. 3019)

NATURENATURE AMOUNTAMOUNT

CompensationCompensation

Business IncomeBusiness Income

Other IncomeOther Income

AMOUNT OF INCOME TAXES PAIDfor the preceding calendar year)

(use additional sheet/s, if necessary)

TOTAL:____________________

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a) The declarant, including his/her spouse and unmarried a) The declarant, including his/her spouse and unmarried children below eighteen (18) years of age living in children below eighteen (18) years of age living in declarant’s household, shall declare their existing interest or declarant’s household, shall declare their existing interest or connection in any business enterprise or entity, aside from connection in any business enterprise or entity, aside from income from government. They shall also indicate the income from government. They shall also indicate the business address, nature of business interest and/or financial business address, nature of business interest and/or financial connection connection (whether as a proprietor, investor, promoter, (whether as a proprietor, investor, promoter, partner, shareholder, officer, managing director, executive, partner, shareholder, officer, managing director, executive, creditor, lawyer, legal consultant or adviser, financial or creditor, lawyer, legal consultant or adviser, financial or business consultant, and the like),business consultant, and the like), and date of acquisition of and date of acquisition of such interest or connection.such interest or connection.

Name of Name of Entity/BusinessEntity/Business

EnterpriseEnterprise

Business AddressBusiness Address Nature of BusinessNature of Business

Interest and/orInterest and/or

Financial ConnectionFinancial Connection

Date of Acquisition of Date of Acquisition of Interest or Interest or ConnectionConnection

3333

b) b) In case there are no existing business In case there are no existing business interests and financial connections in any interests and financial connections in any business enterprise or entity, declarant/s shall business enterprise or entity, declarant/s shall ticktick the box provided for. the box provided for.

I/We don’t have any business interest and financial connections.

3434

a) In case of a) In case of joint filingjoint filing, the declarant and his/her spouse shall disclose their , the declarant and his/her spouse shall disclose their relatives in the government within the relatives in the government within the 4th civil degree of relationship, either 4th civil degree of relationship, either by consanguinity or affinity by consanguinity or affinity (to include (to include bilas, inso, balaebilas, inso, balae). They shall also ). They shall also state their relationship with such relative, relative’s position in the state their relationship with such relative, relative’s position in the government as well as the office name and address.government as well as the office name and address.

Name of Name of RelativeRelative

RelationshipRelationship PositionPosition Name of Name of Office/AddressOffice/Address

3535

b) In case the declarant and his/her spouse, for b) In case the declarant and his/her spouse, for joint joint filingfiling, do not know of any relative/s in the government, , do not know of any relative/s in the government, they shall they shall ticktick the box provided for. the box provided for.

I/We don’t know of any relative/s in Government

3636

a) In case of a) In case of joint filingjoint filing, the declarant and , the declarant and his/her spouse shall sign in the spaces his/her spouse shall sign in the spaces provided for just below the certification.provided for just below the certification.

b) In case of b) In case of separate filingseparate filing, only the declarant , only the declarant shall sign in the space provided for, while the shall sign in the space provided for, while the declarant’s spouse shall sign in the space below.declarant’s spouse shall sign in the space below.

Declarant’s Signature:__________ ______________Date: _____________ Date: __________

(For Separate Filing) Spouse’s Signature:_________ Date:_________________

3737

* * Review and Compliance CommitteeReview and Compliance Committee

Pursuant to Pursuant to Rule VIII of the Rules Rule VIII of the Rules Implementing the Code of Conduct and Implementing the Code of Conduct and Ethical Ethical Standards for Public Officials Standards for Public Officials

andand Employees, as amended by CSC Employees, as amended by CSC Resolution No. 06-0231 dated February 1, Resolution No. 06-0231 dated February 1, 20062006 (re: (re: establishment of a standard review and establishment of a standard review and compliance procedure for the review of compliance procedure for the review of SALNSALN), ), a Review and Compliance Committee a Review and Compliance Committee is is composed of acomposed of a Chairman Chairman and and two (2) two (2) MembersMembers who who shall evaluate the SALN Form shall evaluate the SALN Form submitted to submitted to determine whether it was submitted determine whether it was submitted on on timetime, , accomplished accomplished completelycompletely and and proper in formproper in form..

3838

RemindersRemindersa) a) Declarant is strictly required to fill in all applicable Declarant is strictly required to fill in all applicable information.information.

b) Items not applicable to the declarant should be b) Items not applicable to the declarant should be marked marked N/AN/A (Not Applicable). (Not Applicable).

c) Additional sheets may be used, c) Additional sheets may be used, if necessaryif necessary..

d) Attach all supporting documents, d) Attach all supporting documents, when requiredwhen required..

e) No unnecessary markings shall be made on the e) No unnecessary markings shall be made on the form.form.

3939

* * SanctionSanction

Failure of an official or employee to submit his/her Failure of an official or employee to submit his/her SALN is punishable under SALN is punishable under Section 46 (D) (8), Rule Section 46 (D) (8), Rule X of the Revised Rules on Administrative Cases X of the Revised Rules on Administrative Cases in the Civil Servicein the Civil Service, with the following penalties:, with the following penalties:

1st Offense1st Offense - - Suspension for one (1) Suspension for one (1) month and one (1) day to six (6) monthsmonth and one (1) day to six (6) months

2nd Offense2nd Offense -- Dismissal from the serviceDismissal from the service

4040

Thank You!Thank You!

revised saln form(feb. 1, 2012)

Documents

preceding

acquisition

acquisition

required statements

income taxes

revised saln

acquisition

acquisition