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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. oven rom

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