HRep SALN Form (2019)
Per House Resolution No. 176
(Adopted from the 2015 CSC SALN Form)
SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH (SALN)
As of _________________________
(Required by R.A. 6713 and House Resolution No. 176)
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”.
Joint Filing Separate Filing Not Applicable
DECLARANT: ANTONIO IMELDA B. POSITION: MASTER TEACHER 1
(Family Name) (First Name) (M.I.) UNIT:
ADDRESS: ZONE 2 TARA SIPOCOT, CAMARINES SUR OFFICE:
SIPOCOT SOUTH CENTRAL SCHOOL,
SIPOCOT CAM. SUR
OFFICE ADDRESS: SIPOCOT CAMARINES SUR
SPOUSE: ANTONIO ALEXANDER C. POSITION:
(Family Name) (First Name) (M.I.) OFFICE:
OFFICE ADDRESS:
UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN THE DECLARANT’S HOUSEHOLD
NAME DATE OF BIRTH AGE
ALEX RYAN B. ANTONIO JULY 10, 2002 19
ASSETS, LIABILITIES AND NETWORTH
(Properties owned by the abovenamed unmarried children and exclusive properties of the declarant’s spouse, in case of
separate filing, must be declared in the Separate Sheet/s)
1. ASSETS
a. Real Properties1
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,
and Improvement) Agricultural and Mixed As found in the Latest As found in the Latest
Tax Declaration BIR Zonal Value
YEAR MODE
Use)
RESIDENTIAL ZONE 2 TARA SIPOCOT, 1992
HOUSE CAM. SUR
Total Value of Real Properties (Including those declared in the Additional Sheet, if any):
b. Personal Properties2
DESCRIPTION ACQUISITION ACQUISITION
COST/AMOUNT
YEAR MODE
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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Total Value of Personal Properties (Including those declared in the Additional Sheet, if any):
Total Assets (a + b):
2. LIABILITIES3
NATURE NAME OF CREDITORS OUTSTANDING BALANCE
Total Liabilities (Including those declared in the Additional Sheet, if any):
NET WORTH (Total Assets - Total Liabilities):
BUSINESS INTERESTS AND FINANCIAL CONNECTIONS4
(Business interests and financial connections of the spouse and unmarried children, if any, should be declared in the Separate Sheet/s)
I/We do not have any business interest or financial connection.
NAME OF BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF
ENTITY/ENTERPRISE INTEREST OR FINANCIAL INTEREST OR CONNECTION
CONNECTION
RELATIVES IN THE GOVERNMENT SERVICE5
(Within the Fourth Degree of Consanguinity or Affinity, including 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
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: ______________________________
(Signature of Declarant) (Signature of Co-Declarant/Spouse)
Government Issued ID: Government Issued ID:
ID No.: ID No.:
Date Issued: Date Issued:
SUBSCRIBED AND SWORN to before me this day of , affiant exhibiting to me the above-stated
3
Additional Sheet/s may be used, if necessary.
4
Additional Sheet/s may be used, if necessary.
5
Additional Sheet/s may be used, if necessary.
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government issued identification card.
_______________________________________
(Person Administering Oath)
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