Republic of the Philippines
CIVIL SERVICE COMMISSION
Integrated Records Management Office
REQUEST FOR STATEMENT OF ASSETS, LIABILITIES AND NETWORTH (SALN)
Requesting Party: Nationality
‘Sumame First Namie ‘Middle Name
Residential Address:
(House No. Street, Vitage/Subd,, Barangay, Manisipaliyicily, Province)
Company/Schoo!: Address:
Contact Nos.: 1) 2) 3)
Residences (oitcerSchooy (Wobiey
Requested SALNS:
Name of Declarant
Office/Agency of Declarant [SAIN Year |
Specific Purposes
ity thal my personal iniormation provides abuve are true and correct
: ‘Signature of Requesting Party Date
This portion shall be accomplished by the Processor: ,
Required IDs Presented (at least two): 1
] csisisss 10 # PRC ID# Senior Citizens 1D #
] TIN/PagsibigiPhithealth ID # rece Cn
Lt —! aaa
Passport # oe LUMID (Unified Mutipurpose Identification) #
Driver's License # Current Office 1D # er
Endorsement Letter of Dean/Secretary/Organization
Requested SALNS are available [CT Requested SALNS are not availabe
Processed by: Recommendation: [—] Approval
“Printed Name & Signature) Disapproval/Reason
ACTION TAKEN T
ApprovediDisapproved by:
(Printed Name & Signature)
Number of SALNs. ‘Amount Paid OR#. date
Released by: Received by:
(Printed Name & Signature) (Printed Name & Signature)
NOTES: - Cost per SALN Php30.00
- Except for Name, Other Personal Information of the Declarant will be blackened.
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