Baseline Declaration Form (3/1/2008) SWORN STATEMENT OF ASSETS, LIABILITIES, AND NET WORTH DISCLOSURE OF BUSINESS INTERESTS AND

FINANCIAL CONNECTIONS AND IDENTIFICATION OF RELATIVES IN THE GOVERNMENT SERVICE (Required by R.A. No. 6713) As of ______________________ (Baseline Declaration) Note: Please write your responses in ALL CAPITAL letters using ONLY BALL PEN to avoid blotting. A. DECLARANTS PERSONAL INFORMATION AND EMPLOYMENT
*For Joint filing, make 2 entries for Name, Position, Declarants Annual Gross Salary, Name of Agency, and Office Address *Annual Gross Salary refers to ALL amounts received by declarant from Government service

Last Name

First Name

Middle Name

Home Address

Position

Declarants Annual Gross Salary

* Annual Gross Family Income refers to income of declarant, spouse, and declarants children below 18 years of age living in declarants household

Name of Agency/Office

Office Address

Annual Gross Family Income

I am married. Spouse Information:

I am not married.

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

Name: ________________________________ Position: ____________________ Company: _________________________

B. ASSETS, LIABILITIES, AND NET WORTH

Instruction for all assets: Declare assets whether the declarant/spouse/child is the legal owner (name appearing on the instrument of title) or the beneficial owner (property is in the name of another person but ownership pertains to declarant/spouse/child, under a trust arrangement).
1. Real Properties and Vehicles of Declarant/Spouse/Declarants Children Below 18 Years of Age Living in the Household of Declarant, regardless of amount (Use additional sheet if necessary) I have no real properties to declare owned by me/ my spouse/my children below 18 years of age living in my household I have no vehicles to declare owned by me/my spouse/my children below 18 years of age living in my household Kind of Real Property/ Location of Real Estimated Assessed Property/ Acquisition Fair Market Value (Php) Type of Vehicle and Cert No. and Place Value (Php) plate no. of Reg of Mode Year Cost (Php) (Not Applicable to Vehicle Vehicles)

Total: 2. Investments, Other Personal Properties, and Liabilities of Declarant/Spouse/Declarants Children Below 18 Years of Age Living in the Household of Declarant I have no investments to declare owned by me/my spouse/my children below 18 years of age living in my household I have no personal properties to declare owned by me/my spouse/my children below 18 yrs of age living in my household I have no liabilities to declare pertaining to me/my spouse/my children below 18 years of age living in my household
Instructions: Declare each Asset Item (Investment and Other Personal Property) with a fair market value of Php50,000 or more as of the date of declaration, even if the same was acquired at no cost or at less cost. Declare each Liability Item with an outstanding balance of Php50,000 or more as of the date of declaration. Items with less value may be declared in lump sum as Others. However, if Others amounts to more than Php 100,000, each item must be listed. Put a check mark on the items to be declared, and make the corresponding entry for the actual Acquisition Cost or Outstanding Balance, as applicable.

B.2.1 Investment Item Stocks (equity paid) Bonds Mutual funds Trust funds Private insurance (premiums pd) Educational plans (premiums pd)

Acquisition Cost

B.2.1 Investment Item Pre-need plans (premiums pd) Time deposits Money market placements Equity in partnerships Options Others Total Php:

Acquisition Cost

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B.2.2 Other Personal Property Cash on hand/Bank accounts Receivables Deposits/advanced payments on leases/rentals Furniture, antiques Jewelry Equity in installment purchases Intellectual properties Others

Acquisition Cost

Baseline Declaration Form (3/1/2008) B.2.3 Liability Outstanding Balance Personal loans Bank loans Accounts payables GSIS, PAGIBIG loans Mortgage payables Surety liabilities Guaranty liabilities Judgment debts Loans from other institutions Others Total Php:

Total Php:

3. Net Worth: Declarant/Spouse/Declarants Children Below 18 Years of Age in Declarants Household 1 Reference Section Net Worth At Historical Value (Php) B1 Total Real Properties and Motor Vehicles add: Total Investments B2.1 B2.2 B2.3
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Total Other Personal Properties deduct: Total Liabilities Total Php:

Acquisition costs of Real Properties and Vehicles, and Investments and Other Personal Properties; less total outstanding balance of Liabilities

C. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS OF DECLARANT/SPOUSE/DECLARANTS CHILDREN BELOW 18 YEARS OF AGE LIVING IN THE HOUSEHOLD OF DECLARANT (USE ADDITIONAL SHEET IF NECESSARY)
Instruction: Declare each item which generates gross annual receipts of Php 50,000 or more. Items with less value may be declared in lump sum as Others. However, if Others amounts to more than Php 100,000, each item must be listed

I have no business interests and financial connections to declare pertaining to me/my spouse/my children below 18 years of age living in my household.

Declarant, Spouse, or Child (Put Name)

Name of Entity

Address

Nature of Business Interest/Financial Connection

Date of Acquisition/ Connection

D. DECLARANTS RELATIVES IN THE GOVERNMENT (USE ADDITIONAL SHEET IF NECESSARY) th Instruction: Up to the 4 civil degree of relationship, either of consanguinity or affinity, including bilas, inso and balae I dont know of any relatives in Government.

Name of Relative

Relationship

Position

Office/Address

E. STATEMENT
I hereby certify to the best of my knowledge and information that these are complete and true statements of my assets, liabilities, net worth, business interests, and financial connections, including those of my spouse and my children below 18 years of age living in my household, and the names of my relatives in the Government, as of ______________________________, as required by and in accordance with Republic Act No. 6713. I further certify that no assets, liabilities, business interests, financial connections, and relatives in the Government other than those declared herein are known to me, my spouse, and my children below 18 years of age living in my household. I hereby authorize the Ombudsman or his duly authorized representative to obtain and secure from all appropriate government agencies, including the Bureau of Internal Revenue, such documents that may show such assets, liabilities, net worth, business interests, and financial connections, including those of my spouse and my children below 18 years of age living in my household, covering previous years, including the year I first assumed office in Government. I further undertake to produce all supporting documents for each of the entries herein made when required. Declarants Signature: _____________________________________________ Date ________________ TIN: ______________________ Community Tax Cert No: ___________________________ Issued In: ___________________________ Issued On: __________________ In case of joint filing: Spouses Signature: ___________________________________________ Date __________________ TIN: ________________________ Community Tax Cert No: ___________________________ Issued In: _________________________ Issued On: ____________________ SUBSCRIBED AND SWORN TO before me on this _______________day of _________________________________, 20______, affiant(s) exhibiting his/her/their Community Tax Certificate(s) as indicated above. ________________________________ (Person Administering Oath)

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Baseline Declaration Form (3/1/2008) F. GENERAL INSTRUCTIONS FOR BASELINE DECLARATION

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Please write your responses in ALL CAPITAL letters using ONLY BALL PEN to avoid blotting. The Baseline Declaration (BD), which contains a comprehensive listing of your assets, liabilities, net worth, business interests, and financial connections, must be submitted by new entrants within 30 days after assumption into office, and by incumbents on or before April 30, 2008. This form must be accomplished only once. The statement of a new entrant must contain comprehensive information as of his/her first day of Government service. The statement of an incumbent must contain his/her assets, liabilities and networth as of December 31, 2007. The BD must be accomplished in triplicate, of which two (2) copies must be submitted to the Administration/Personnel Division/Unit of your agency. For joint filing by husband and wife, make two (2) entries in Section A for the Name, Position, Annual Gross Salary, Name of Agency/Office, and Office Address. Also, the co-declarant must sign the Statement under Section E. You may use additional forms or sheets if information exceeds the spaces provided. Put N/A for each entry that does not apply to you. You must provide information for your spouse, if any, regardless of the status of marriage, except only when your marriage has been declared null and void; has been annulled; or a decree of legal separation has been procured, with finality. You must provide information for all your children below 18 years of age living in your household, regardless of legitimacy or illegitimacy. The fair market value of real property is that amount which a willing buyer and a willing seller can agree on as the purchase price of the property. You may refer to historical data, such as sales transactions of real properties, in the same vicinity. The assessed value of real property is that recorded in the Assessors Office, the local Treasurer, or the Sanggunian in the city or municipality where the real property is located. Note that you are not required to attach any documents to vouch for or substantiate the information disclosed at the time of submission. However, you must ensure that all information provided is supported by proper and adequate documentation, and must be prepared to produce the same when required in the future. Moreover, the SALN is made under oath. Falsification of information or failure to file or report information may subject you to disciplinary action. Deliberate and willful falsification of information may also subject you to criminal prosecution. Penalties under RA 6713 may be any of the following: Imprisonment five years Fine PhP 5, 000 Dismissal from the service For further guidance, SALN Manual: A Guide to Filling Out Your SALN Form is available from the Civil Service Commission and your Human Resource Division. You may also contact the Integrated Records Management Office (IRMO) at 931-7981, 931-7987, and 951-4628 for assistance in completing the SALN.

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