[ ^C^pULJIlV-/ Ul LI IC7 I I lllip|-'n IC^O

depar
tment of @r
aratton
Region VII, Central Visayas
DIVISION OF BOHOL
City of Tagbilaran

January 7, 2017

DIVISION MEMORANDUM
No. O\ , s. 2017

Submission of 2016 Statement of Assets, Liabilities and Net Worth (SALN)

To : ASDS & Chief-EPS

Education Program Supervisors
Public Schools Distr
ict Supervisors & Acting-PSDS
Public Secondary & Elementary School Heads
Teaching & Teaching Related Positions
Non-Teaching Personnel
All Other Concerned

1. Pursuant to R.A. 6713, re Code of Conduct & Ethical Standard, all officials and
employees are required to file under oath their Statement of Assets, Liabilities and Net Worth
and a Disclosure of Business Interests and Financial Connections and those of their spouses and
unmarried children under eighteen (18) years of age living in their households as of December
31,2016.

2. For the information and guidance of all concerned, this office therefore announces the
composition of the Committee to Review on the accomplished SALN to ensure 100%
submission as well as the accuracy and completeness of entries considering that this report is
part of the requirements and compliance of the yearly Performance Based Bonus, thus, no
SALN no granting of PBB for 2016. Below is the committee on SALN Review:
Chairman: Fermin M. Albutra
Vice Chair: Mr. Freder
ick Namoc
Members: Mrs. Emelyn Bompat
Mr. Marlon Jongson "r
Mrs. Mira Bersaluna

3. The deadline for submission of the accomplished SALN form for 2016 is on January 31,
2017 at the Human Resource Management Office with list of permanent employees using the
attached template per School. This is to give ample time for review and validation of reports due
to urgent submission of the same documents to the Office of the Ombudsman-Visayas on the
first week of March, 2017. Prompt and on time submission is str ictly observed. Officials and
employees who cause the delay ofsubmission to this office shall be liable and responsible for the
submission of this report to the Office ofthe Ombudsman for the Visayas.

4. Failure of an official or employee to submit his/her SALN is punishable under Sec. 52

(B), Rule rV of the Uniform Rules on Administrative Cases in the Civil Service, with the
following penalties: 1st Offense @ Suspension for One (1) month and One (1) day to Six (6)
months; 2nd Offense @ Dismissal from the service.

5. Immediate and wide dissemination ofthis Memorandum is desired.

WBLFREDA D. BONGALOS, Ph.D., CESO VI ,

Schools Division Superintendent q
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SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH

(Required by R.A. 6713)

Note: Husband and wife who are bothpublic of

icials and employees mayf
f ile the required statementsjointly or separately.
? Joint Filing ? Separate Filing Q Not Applicable

DECLARANT: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:
ADDRESS: OFFICE ADDRESS:

SPOUSE: POSITION:
(Family Name) (First Name) (M.I.) AGENCY/OFFICE:
OFFICE ADDRESS:

UNMARRIED CHILDREN BELOW EIGHTEEN (18) YEARS OF AGE LIVING IN DECLARANT'S HOUSEHOLD

NAME DATE OP BIRTH AGE

ASSETS, LIABILITIES AND NETWORTH

(Including those ofthe spouse and unmarried children below eighteen (18)
years ofage living in declarant's household)

1. ASSETS
a. Real Properties*

LOCATION CURRENTFAIR ACQUISITION ACQUISITIONCOST

(eg.lot,houseand. (eg.residential, VALUE MARKETVAtUE
lot,condominium commercial,industr ial,
andimprovements]agriculturalandmixed (AsfoundintheTaxDeclarationof YEAR MODE
use) RealPr
operty)

'@"V

Subtotal:
b. Personal Properties*

Subtotal:
TOTAL ASSETS (a+b):
2. LIABILITIES*

lf
l1Ti5)(oT5l(c<:<:n )mo):*.
 BUSINESS INTERESTS AND FINANCIAL CONNECTIONS
(ofDeclarant /Declarant's spouse/ Unmarried Children Below Eighteen (18) years of Age Living in Declarant's Household)

? I/Wedo not have any businessinterestorf

inancialconnection.

nameofentity//business ,4,NATURE*OF,,BJ3[S;iNESS ';, VDATE.OFACQUISITION'OF,

, enterprise';, INTERESTC&r^pR,FINANCIAL INTERESTOR'CONNECTION
U@ ,
'v CONNECTIO'N"

RELATIVES IN THE GOVERNMENT SERVICE

(Within the FourthDegree, ofConsanguinity orAf
finity. Include also BUas, Balae and Inso)
? I/We do not know ofany relative/s in the government service)

I hereby certif
y that these are true and correct statements of ray assets, liabilities, net worth,
business interests and f
inancial 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 f
irst assumed office in government.

Date:

(Signature ofDeclarant) (Signature ofCo-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
government issued identification card.