HRep SALN Form (2019)

Per House Resolution No. 176

(Adopted from the 2015 CSC SALN Form)

SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH (SALN)

As of 31 December 2019
(Required by R.A. 6713 and House Resolution No. 176)

Note: Husband and wife who are both public officials/employees may file their SALN jointly or separately. The declarant who is single, widowed,
divorced or annulled or married to a private person shall tick off the box marked below as “Not Applicable”.

 Joint Filing  Separate Filing  Not Applicable

DECLARANT: DOROMAS KIMBEERLYN C. POSITION: TEACHER I

(Family Name) (First Name) (M.I.) UNIT: N/A
ADDRESS: OFFICE: DEPARTMENT OF EDUCATION-
PRK. VICENTE FIN, BARANGAY MAGSAYSAY, POLOMOLOK NORTH DISTRICT
POLOMOLOK, SOUTH COTABATO OFFICE ADDRESS: POLO, SOUTH COTABATO

SPOUSE: DOROMAS ALLAN D. POSITION: N/A

(Family Name) (First Name) (M.I.) OFFICE: N/A
OFFICE ADDRESS: N/A

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

NAME DATE OF BIRTH AGE

DOROMAS, KIAN CLARK C. MARCH 13, 2013 6
DOROMAS, KAIZEN C. MARCH 04, 2017 2

ASSETS, LIABILITIES AND NETWORTH

(Properties owned by the abovenamed unmarried children and exclusive properties of the declarant’s spouse, in case of
separate filing, must be declared in the Separate Sheet/s)
1. ASSETS
a. Real Properties1

DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION

(e.g. Lot, House and (e.g. Residential, LOCATION VALUE MARKET VALUE COST
Lot, Condominium Commercial, Industrial,
As found in the Latest As found in the Latest
and Improvement) Agricultural and Mixed YEAR MODE
Use) Tax Declaration BIR Zonal Value

NONE NONE NONE NONE NONE NONE NONE NONE

Total Value of Real Properties (Including those declared in the Additional Sheet, if any):
2
b. Personal Properties

DESCRIPTION ACQUISITION ACQUISITION

COST/AMOUNT
YEAR MODE

PRINTER 2019 P 5,000.00

MOTORCYCLE / TRICYCLE 2017 P 90,000.00
APPLIANCES 2016 P 5,000.00
ACER NETBOOK 2015 P 20,000.00P
Total Value of Personal Properties (Including those declared in the Additional Sheet, if any): P 120,000.00
Total Assets (a + b): P 120,000.00

1
Additional Sheet/s may be used, if necessary. In case of joint filing, the list should include the exclusive properties of the spouse.
2
Additional Sheet/s may be used, if necessary. In case of joint filing, the list should include the exclusive properties of the spouse.
Page 1 of ___
 2. LIABILITIES3
NATURE NAME OF CREDITORS OUTSTANDING BALANCE

NONE NONE NONE

Total Liabilities (Including those declared in the Additional Sheet, if any):

NET WORTH (Total Assets - Total Liabilities):

P 120,000.00

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS4

(Business interests and financial connections of the spouse and unmarried children, if any, should be declared in the Separate Sheet/s)

 I/We do not have any business interest or financial connection .

NAME OF BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF

ENTITY/ENTERPRISE INTEREST OR FINANCIAL INTEREST OR CONNECTION
CONNECTION
NONE NONE NONE NONE

RELATIVES IN THE GOVERNMENT SERVICE5

(Within the Fourth Degree of Consanguinity or Affinity, including Bilas, Balae and Inso)

 I/We do not know of any relative/s in the government service)

NAME OF RELATIVE RELATIONSHIP POSITION NAME OF AGENCY/OFFICE AND ADDRESS
MIGUEL FILLALAN JR. UNCLE OIC-ASSISTANT DEPARTMENT OF EDUCATION, KIDAPAWAN CITY
SCHOOLS
DIVISION
SUPERINTENDENT

I hereby certify that these are true and correct statements of my assets, liabilities, net worth,
business interests and financial 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 first assumed office in government.

Date: FEBRUARY 05, 2020

(Signature of Declarant) (Signature of Co-Declarant/Spouse)

Government Issued ID: SSS / UMID Government Issued ID: DRIVER’S LISCENSE
ID No.: 09-4087117-9 ID No.: L05-10-001590
Date Issued: JANUARY 2013 Date Issued: FEBRUARY 4, 2019

SUBSCRIBED AND SWORN to before me this day of , affiant exhibiting to me the above-stated
government issued identification card.

_______________________________________
(Person Administering Oath)

3
Additional Sheet/s may be used, if necessary.
4
Additional Sheet/s may be used, if necessary.
5
Additional Sheet/s may be used, if necessary.
Page 2 of ___
 SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH (SALN)
As of 31 December 2018
(Required by R.A. 6713 and House Resolution No. 176)

ADDITIONAL SHEET
Note: This Additional Sheet may be used to declare additional list of declarant’s assets, liabilities and financial interests and
financial connections, including those of the declarant’s spouse in case of joint filing.

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

1.a. Declarant’s Real Properties (Additional)

DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION

(e.g. lot, house and (e.g. residential, LOCATION VALUE MARKET VALUE COST
lot, condominium commercial, industrial,
As found in the Latest As found in the Latest
and improvement) agricultural and mixed YEAR MODE
use) Tax Declaration BIR Zonal Value

Subtotal of Real Properties Declared in this Additional List:

1.b. Declarant’s Personal Properties (Additional)

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

Subtotal of Personal Properties Declared in this Additional List:

2. LIABILITIES (Additional List)

NATURE NAME OF CREDITORS OUTSTANDING

BALANCE

Subtotal of Liabilities Declared in this Additional List:

BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (Additional)

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF

ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION

Page 3 of ___
 SWORN STATEMENT OF ASSETS, LIABILITIES AND NET WORTH (SALN)
As of 31 December 2018
(Required by R.A. 6713 and House Resolution No. 176)

SEPARATE SHEET
Note: This Separate Sheet shall be used in declaring (1) exclusive properties of the declarant’s spouse except in case of joint filing;
(2) properties owned by the declarant’s unmarried children below 18 years of age living in the declarant’s household; and
(3) their business interests and financial connections.

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

A. ASSETS
1. Real Properties (Separate)

DESCRIPTION KIND EXACT ASSESSED CURRENT FAIR ACQUISITION ACQUISITION

(e.g. lot, house and (e.g. residential, LOCATION VALUE MARKET VALUE COST
lot, condominium commercial, industrial,
As found in the Latest As found in the Latest
and improvement) agricultural and mixed YEAR MODE
use) Tax Declaration BIR Zonal Value

Total Value of Real Properties of the Declarant’s Spouse and Unmarried Children:

2. Personal Properties (Separate)

DESCRIPTION YEAR ACQUIRED ACQUISITION

COST/AMOUNT

Total Value of Personal Properties of the Declarant’s Spouse and Unmarried Children:

B. LIABILITIES (Separate)

NATURE NAME OF CREDITORS OUTSTANDING

BALANCE

Total Personal Liabilities of the Declarant’s Spouse:

C. BUSINESS INTERESTS AND FINANCIAL CONNECTIONS (Separate)

NAME OF ENTITY/BUSINESS BUSINESS ADDRESS NATURE OF BUSINESS DATE OF ACQUISITION OF

ENTERPRISE INTEREST &/OR FINANCIAL INTEREST OR CONNECTION
CONNECTION

Page 4 of ___