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 December 31, 2018
(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 Separate Filing Not Applicable
DECLARANT: SALAMA NORHAYNIE M. POSITION: TEACHER I
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: MASIRICAMPO ABANTAS MEMORIAL
NATIONAL HIGH SCHOOL I
ADDRESS: ZAMORA ST., BRGY. MANILA GROUP, OFFICE ADDRESS: DIVISION OF LANAO DEL SUR I,
BRGY. MANILA GROUP,
WAO, LANAO DEL SUR WAO, LANAO DEL SUR
SPOUSE: SALAMA AMER T. POSITION: N.A.
(Family Name) (First Name) (M.I.) AGENCY/OFFICE: N.A.
OFFICE ADDRESS: N.A.
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT’S HOUSEHOLD
NAME DATE OF BIRTH AGE
1. SITTIE AZNAIRAH M. SALAMA SEPTEMBER 9, 2009 9
2. NORJANAH M. SALAMA OCTOBER 7, 2007 8
3. PRINCESS AMERAH M. SALAMA JUNE 16, 2016 2
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ASSETS, LIABILITIES AND NETWORTH
(Including those of the spouse and unmarried children below eighteen (18)
years of age living in declarant’s household)
1. ASSETS
a. Real Properties*
DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION
(e.g. lot, house and (e.g. residential, LOCATION VALUE MARKET VALUE COST
lot, condominium commercial, industrial,
(As found in the Tax Declaration of
and improvements) agricultural and mixed YEAR MODE
use) Real Property)
N.A N.A. N.A. N.A. N.A. N.A. N.A. 0
N.A. N.A. N.A. N.A. N.A. N.A. N.A. 0
N.A. N.A. N.A. N.A. N.A. N.A. N.A. 0
N.A. N.A. N.A. N.A. N.A. N.A. N.A. 0
Subtotal: 0
b. Personal Properties*
DESCRIPTION YEAR ACQUIRED ACQUISITION
COST/AMOUNT
APPLIANCES (ELECTRIC FAN, REFRIGERATOR, TV, RICE VARIOUS YEARS Php 72,000.00
COOKER, WASHING MACHINE, ELECTRIC STOVE, ETC.)
FURNITURES (DINING TABLE, CABINET, SALA SET, BED VARIOUS YEARS 75,000.00
MATTRESS, ETC. )
ELECTRONIC GADGETS (CELLPHONES, PRINTER) VARIOUS YEARS 20,000.00
JEWELRIES (EARINGS) VARIOUS YEARS 18,000.00
PERSONAL BELONGINGS (FOOTWEARS, CLOTHING, BAGS, ETC.) VARIOUS YEARS 30,000.00
Subtotal : Php 215,000.00
TOTAL ASSETS (a+b):
Php 215,000.00
* Additional sheet/s may be used, if necessary.
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2. LIABILITIES*
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
CONSOL LOAN GSIS Php 137,489.99
POLICY LOAN GSIS 16,881.90
SALARY LOAN PPSTA 241,100.00
- - -
TOTAL LIABILITIES: Php 395,478.89
NET WORTH : Total Assets less Total Liabilities = -Php 180,478.89
* Additional sheet/s may be used, if necessary.
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(of Declarant /Declarant’s spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarant’s Household)
I/We do not have any business interest or financial connection .
NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF
ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
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
REMIA M. BUGAHOD AUNT SUPERVISOR DEPARTMENT OF AGRARIAN
REFORM/CAGAYAN DE ORO CITY
NOEMIE M. PAGAYON AUNT PRINCIPAL DEPARTMENT OF EDUCATION/ VALENCIA
CITY
- - - -
- - - -
- - - -
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: ___JANUARY 25, 2019_______
(Signature of Declarant) (Signature of Co-Declarant/Spouse)
Government Issued ID: TIN Government Issued ID: N.A.
ID No.: 950-601-152 ID No.: N.A.
Date Issued: 06-25-12 Date Issued: N.A.
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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