Republic of the Philippines)

DONE:In the City of Tabuk)S.S.

AFFIDAVIT

I, FLEMA B. WACDAGAN, of legal age, married, Filipino citizen

and with residence and postal address at Purok 1, Bulanao Centro, Tabuk
City, Philippines, after having been duly sworn to in accordance with law
hereby depose and state that:

1. I am the school head of Lubo Elementary School;

2. On September 8, 2021, we facilitated the enrolment of our students at

our school since it is the enrolment period for the school year 2021-
2022, hence the teachers of each grade level are required to attend;

3. On 4:30 pm, we ended the enrolment for that day and me and my
fellow teachers left to go to our respective homes;

4. Unfortunately, one of our fellow teachers, Mrs. Narcisa A.

Bongabong, while traversing the pathway going to their house figured
in a mishap thereby causing a slight injury on her; A copy of her
medical certificate is hereto attached for reference;

5. According to her, while she was carrying a small rock purposely to

place it in the muddy pathway for her to step on, she suddenly slipped
thereby causing her to fall on her back.

6. I am executing this affidavit to attest to the truthfulness of the

foregoing declarations to support her application for rehabilitation on
her injury and for all legal intents and purposes this may serve.

IN WITNESS WHEREOF, I have hereunto affix my signature this

16 day of September 2021 at Tabuk City, Philippines.
th

FLEMA B. WACDAGAN
Affiant

SUBSCRIBED AND SWORN TO BEFORE me this 16th day of

September 2021 at Tabuk City, Philippines.

Doc. No. _____

Page No. _____
Book No. _____
Series of 2021