REPUBLIC OF THE PHILIPPINES )

Province of South Cotabato ) S.S.

Municipality of Polomolok )
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AFFIDAVIT OF ACCIDENT

I, RANILO R. RADANA, Filipino, of legal age, and a resident of Brgy. Cannery

Polomolok, South Cotabato, Philippines, after being duly sworn in accordance with law, depose
and state THAT:

1 On 25 July 2020 at around 10:30 in the morning, I was working at the premises of
Pavilion, Dole Philippines, Cannery Site, Polomolok, South Cotabato;
2 While working, I cut the rubber, and accidentally cut my transected flexor tendons
5th and 4th finger of left hand, which resulted to bleeding;
3 I was immediately referred to Howard Hubbard Memorial Hospital for immediate
medical attention, which then requires my admission for 2 days;
4 As such, I am executing this Affidavit for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 29th of July 2020 at
Polomolok, South Cotabato, Philippines.

RANILO R. RADANA
Affiant

SUBSCRIBED AND SWORN to before me, this 29th of July 2020 at Polomolok, South
Cotabato by the Affiant whom I have identified through competent evidence of identity.

ATTY. DARLENE D. GILBUENA

Public Attorney II
Pursuant to R.A. 9406