REPUBLIC OF THE PHILIPPINES )

Province of South Cotabato ) S.S.

Municipality of Polomolok )
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AFFIDAVIT OF ACCIDENT

I, JUNARD P. SABELLANO Filipino, of legal age, and a resident of Lantana Subd.,

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

1 On 10 September 2020 at around 6:30 in the morning, I was at the abovementioned

residence. While shoveling, I accidentally hit my nails at the round bar which
resulted to an injury or damage to my 4th digit right hand nail;
2 I was immediately referred to Dr. Arnel L. De Leon for immediate medical attention,
and was required to rest at home for a week;
3 As such, I am executing this Affidavit for whatever legal purpose it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this 14th of September 2020 at
Polomolok, South Cotabato, Philippines.

JUNARD P. SABELLANO
Affiant

SUBSCRIBED AND SWORN to before me, this 14th of September 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