POEA.
REPUBLIC OF KENYA
THE PUBLIC OFFICER ETIHCS ACT, 2003
(No. 4 of 2003)
Declaration of Income, Assets & Liabilities (section 26)
1. Name of the Public Officer
(Surname) (First name) (Other names)
_________________________________________________________________________________
2. Birth Information
a. Date of birth __________________________________________________________
b. Place of birth _________________________________________________________
3. Marital Status _______________________________________________________________
4. Address
a. Postal address ________________________________________________________
b. Physical address _______________________________________________________
5. Employment Information
a. Designation __________________________________________________________
b. Name of Employer ____________________________________________________
c. Nature of employment (permanent, temporary, contract, etc)
____________________________________________________________________
d. T.S.C. No. ___________________________________________________________
e. School/Institution ______________________________________________________
f. District ______________________________________________________________
6. Name of spouse of spouses
(i) (Surname) (First name) (Other names)
___________________________________________________________________________
(ii) (Surname) (First name) (Other names)
___________________________________________________________________________
iii) (Surname) (First name) (Other names)
___________________________________________________________________________
(iv) (Surname) (First name) (Other names)
___________________________________________________________________________
(v) (Surname) (First name) (Other names)
___________________________________________________________________________
(vi) (Surname) (First name) (Other names)
___________________________________________________________________________
(vii) (Surname) (First name) (Other names)
___________________________________________________________________________
7. Name of dependent children under the ages of 18 years
(i) (Surname) (First name) (Other names)
___________________________________________________________________________
(ii) (Surname) (First name) (Other names)
___________________________________________________________________________
(iii) (Surname) (First name) (Other names)
___________________________________________________________________________
(iv) (Surname) (First name) (Other names)
___________________________________________________________________________
(v) (Surname) (First name) (Other names)
___________________________________________________________________________
(vi) (Surname) (First name) (Other names)
___________________________________________________________________________
(vii) (Surname) (First name) (Other names)
___________________________________________________________________________
(viii) (Surname) (First name) (Other names)
___________________________________________________________________________
(ix) (Surname) (First name) (Other names)
___________________________________________________________________________
8. Financial statement for ________________________________________________________
(A separate statement is required for the officer and each spouse and dependent child under the age
of 18 years. Additional sheets should be added as required)
a. Statement date
(Statement date is the first day of the month preceding the month in which the declaration is due.)
b. Income, including emoluments, for the period from
_____________________________________to________________________________________
(Including, but not limited to, salary and emoluments and income from investments, the period is
from the previous statement date to the current statement date. For an initial declaration, the period is
the year ending on the statement date.)
Description Approximate amount
c. Assets (as of the statement date)
(Including, but not limited to land, buildings, vehicles, investments and financial obligations owed to
the person for whom the statement is made)
Description Approximate amount
(Including the location of asset where
applicable)
d. Liabilities (as of the statement date)
Description Approximate amount
9. Other information that may be useful or relevant
I solemnly declare that the information I have given in this declaration is, to the best of
my knowledge, true and complete.
Signature of Officer: ________________________________________________________________
Date: ____________________________________________________________________________
Witness:
Signature: ____________________________________________________________
Name: _______________________________________________________________
Address: ________________________________________________________
