Republic of the Philippines )

City of Davao )s.s.

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AFFIDAVIT OF EXPLANATION

I, SEAN MARK E. ACHUMBRE, of legal age, married, Filipino, and with office
address at Door 5 & 6, K7 Strip Bldg., Km. 7 Lanang, Davao City, Philippines, after having
been sworn to in accordance with law, do hereby depose and say state that:

1. I am a Senior Warehouseman at Civic Merchandising, Inc., with office address

located at Door 5 & 6, K7 Strip Bldg., Km. 7 Lanang, Davao City;

2. On September 3, 2018 at around 8:00 o’clock in the morning, I boarded a public

utility van with temporary plate number 1324-780134 on my way to the office.
Unfortunately however, the aforesaid vehicle figured an accident while traversing
the road of Bunawan, Davao City. A copy of the Police Blotter is hereto attached
as Annex “A ” to form an integral of this affidavit;

3. Due to the impact of the collision, I was left unconscious. When I woke up, I was
already at the Southern Philippines Medical Center (SPMC), Davao City. As a
result of the accident, I suffered some injuries in my right side rib and underwent
a Closed Tube Thoracostomy. A copy of the Clinical Summary is hereto attached
as Annex “B ” to form an integral of this affidavit;

4. If it were not for the said unfortunate accident, I would have entered my Daily
Time-In Record (DTR) and be present at my workplace. Sadly, however, I was
confined at SPMC for medical attention instead of attending my work;

5. I am executing this affidavit, together with its supporting documents, in order to

claim benefits from the Social Security System (SSS) resulting from the injuries
that I have suffered and to further attest to truth and veracity of the foregoing
statements and for all other legal intents and purposes it may serve best.

IN WITNESS WHEREOF, I have hereunto set my hand on this _______________

at Davao City, Philippines.

SEAN MARK E. ACHUMBRE

Affiant

SUBSCRIBED AND SWORN to before me on this ___________ at Davao City,

Philippines, affiant exhibited to me his sufficient evidence of identity with SSS No. 09-
2248857-7.

Doc. No. ;
Page No. ;
Book No. ;
Series of 2019.