Use of the 1994 Statement of Assets, Liabilities and Net Worth (SALN) Form (Old Form) for the Year 2010

March 3, 2011 BIR MEMORANDUM TO : All BIR Officials/Employees SUBJECT : Use of the 1994 Statement of Assets, Liabilities and Net Worth (SALN) Form (Old Form) for the Year 2010 Pursuant to Section 8 of Republic Act No. 6713 as implemented by Memorandum Circular No. 10, Series of 2006 issued by the Civil Service Commission, all public officials and employees are required to file under oath their Statement of Assets, Liabilities and Net Worth (SALN) Old Form (Annex "A") and Disclosure of Business Interest and Financial Connections. HCDaAS This shall be filed and distributed as follows: National Office Regional Office Original Copy Civil Service Commission Office of the Ombudsman (Central Office) Luzon Ombudsman Central Office, Agham Road, Diliman, Quezon City Visayas Deputy Ombudsman for Visayas Cebu Mindanao Deputy Ombudsman for Mindanao, Davao Second Copy Personnel Division Human Resource Management Unit (201 File) (201 File) Third Copy Personal File Personnel Division (201 File) Fourth Copy Personal File In addition to these requirements all offices in the National Office and HRMUs in the Regional Offices are required to submit the following: National Office Alphabetical list of all employees in their respective office (per CPS), Alphabetical list of all filers (Annex "B") and non filers (Annex "C") duly certified by the head of office (hard and soft copy). The soft copy shall be transmitted via flash drive or e-mail to [emailprotected] or [emailprotected]. Regional Office Copy of transmittal, Alphabetical list of filers (Annex "B") and non filers (Annex "C") certified by the Regional Director or Head of HRMU and duly received by the Deputy Ombudsman in their respective region. The deadline for submission of the accomplished 1994 SALN Form to the Personnel Division/HRMU is April 29, 2011. All information and details in the SALN are required to be filled up. Items not applicable should be marked N/A (not applicable) or None as the case may be. No SALN shall be accepted if the fields are left blank. Additional form or sheets may be used if the information exceeds the spaces provided. Spouses working in government service may file their SALN separately or jointly. In case of joint filing both must sign the statement, indicate the date of signing, TIN and CTC details, and personally subscribe the SALN before a person authorized to administer oaths and submit the necessary copies (3 for N.O. & 4 for Region) as provided for in this memorandum. AECacS Failure to file said sworn statement would be in violation of the provisions of Section 8 (A) of Republic Act No. 6713 and Rule VII, Section I of Implementing Rules. Strict compliance is hereby enjoined. (SGD.) CELIA C. KING Deputy Commissioner Resource Management Group ANNEX A Sworn Statement of Assets, Liabilities and Networth Disclosure of Business Interest and Financial Connections and Identification of Relatives in the Government Service as of December 31, 2010 (Required by R.A. No. 6713) Name: ________________________________ Position: __________________ Surname First Name MI Income: __________________ Address: ________________________________ Office Address: __________________ ________________________________ __________________ Spouse: ________________________________ Office: __________________ Surname First Name MI Unmarried Children Below 18 years of age: Name of Children Date of Birth _______________________________ _________________________________________ _______________________________ _________________________________________ _______________________________ _________________________________________ _______________________________ _________________________________________ _______________________________ _________________________________________ A. Assets, Liabilities and Net Worth 1. Assets A. Real Properties Kind Location Year Mode of Nature of Assessed Current Acquisition Cost Acquired Acquisition Property Value Fair Land Improvements (paraphernal Market Building conjugal Value etc. or community) _____ ________ ______ ___________ ____________ ______ ________ __________ ____________ _____ ________ ______ ___________ ____________ ______ ________ __________ ____________ _____ ________ ______ ___________ ____________ ______ ________ __________ ____________ _____ ________ ______ ___________ ____________ ______ ________ __________ ____________ _____ ________ ______ ___________ ____________ ______ ________ __________ ____________ Total ____________ B. Personal and other properties Kind Year Acquired Acquisition Cost _____________________ ______________ ___________________ _________ _____________________ ______________ ___________________ _________ _____________________ ______________ ___________________ _________ _____________________ ______________ ___________________ _________ _____________________ ______________ ___________________ _________ _____________________ ______________ ___________________ _________ _____________________ ______________ ___________________ _________ Total _________ 2. Liabilities (Loans, mortgage, etc.) Nature Name of Creditors Amount ___________________ ____________________________ _________________ ___________________ ____________________________ _________________ ___________________ ____________________________ _________________ ___________________ ____________________________ _________________ ___________________ ____________________________ _________________ Total _________________ Networth: Total Assets (1A + 1B) less total liabilities (2) (Note: Please use additional format/sheets if necessary Also, please reproduce this form back to back.) B. Business Interests and Financial Connections Do you have any business interests and other financial connections including those of your spouse and unmarried children below 18 years of age living with you in your household? [ ] Yes [ ] No If yes, give particulars. Name Name of Firm/ Nature of Date of Company Address Business Interest Acquisition and/or Financial Connection Connection ______________ ____________ ____________ ________________ _______________ ______________ ____________ ____________ ________________ _______________ ______________ ____________ ____________ ________________ _______________ ______________ ____________ ____________ ________________ _______________ ______________ ____________ ____________ ________________ _______________ ______________ ____________ ____________ ________________ _______________ ______________ ____________ ____________ ________________ _______________ C. Identification of Relatives in the Government Service To the best of your knowledge, are you related within the fourth degree of consanguinity of affinity to anyone working in the government? [ ] Yes [ ] No If yes, give particulars. Name Position Relationship Name/Address of Office ________________ ____________ ________________ ________________________ ________________ ____________ ________________ ________________________ ________________ ____________ ________________ ________________________ ________________ ____________ ________________ ________________________ ________________ ____________ ________________ ________________________ ________________ ____________ ________________ ________________________ I hereby certify to the best of my knowledge and information, that these are true statements of my assets, liabilities, networth, business interests and financial connections, including those of my spouse and unmarried children below 18 years of age and names of my relatives in the government as of December 31, 2010 as required by and in accordance with Re public Act 67 13. 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 my assets, liabilities, networth, 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. SECIcT Date: ______________________ __________________________ __________________________ Signature of Spouse Signature TIN: _____________________ TIN: _______________________ Com. Cert. No. _____________________ Com. Cert. No. ________________ Issued at _____________________ Issued at ________________ Date Issued _____________________ Date Issued ________________ SUBSCRIBED AND SWORN TO before me this ________ day of _______________ 2011 affiant exhibiting his/her Residence Certificate as indicated above. _________________________ Person Administering Oath REPUBLIC OF THE PHILIPPINES DEPARTMENT OF FINANCE BUREAU OF INTERNAL REVENUE Quezon City April 29, 2011 CERTIFICATION This is to certify that the following officials/employees of this Office, have submitted their Statement of Assets, Liabilities and Net worth (SALN) and Disclosure of Business Interest and Financial Connections and Identification of Relatives in the Government Service for the year 2010 as required under Section 8 of Re public Act No. 67 13 as implemented by Memorandum Circular No. 10, Series of 2006 issued by the Civil Service Commission. No. Name of Officials/ TIN Position Net Worth Employees 1 ____________________ ____________ _____________ ______________ 2 ____________________ ____________ _____________ ______________ 3 ____________________ ____________ _____________ ______________ 4 ____________________ ____________ _____________ ______________ 5 ____________________ ____________ _____________ ______________ 6 ____________________ ____________ _____________ ______________ 7 ____________________ ____________ _____________ ______________ 8 ____________________ ____________ _____________ ______________ 9 ____________________ ____________ _____________ ______________ This certification is issued in compliance with BIR Memorandum dated March 3, 2011. Name Chief, Division April 29, 2011 CERTIFICATION This is to certify that the following officials/employees listed below, have not submitted their Statement of Assets, Liabilities and Networth (SALN) and Disclosure of Business Interest and Financial Connections for the year 20 10 pursuant Section 8 of Repu blic Act No. 67 13 as implemented by Memorandum Circular No. 10, Series of 2006 issued by the Civil Service Commission, to wit: Name of Official/Employee Designation/Position 1. 2. This certification is issued in compliance with BIR Memorandum dated March 3, 2011. ACaTIc NAME Chief, Division