REPUBLIC OF THE PHILIPPINES )

MUNICIPALITY OF Diffun ) S.S.

x-------------------------------------------------------x

AFFIDAVIT OF EXEMPT STATUS UNDER THE WORKERS’

COMPENSATION ACT
I, ALFONSO U. DANTES II state under oath as follows:

1. I, ALFONSO U. DANTES II is operating as Volunteer Teacher in Diffun National High School without
compensation;

2. I understand that based upon the representations in this Affidavit of Exempt Status, I am requesting Diffun
National High school to consider my business to be that of an independent contractor; that I am not an
employee under the Workers’ Compensation Act and the policy issued by Diffun National High School ;
and that no premium be charged for the services performed by my business during the policy year;

3. I am an independent contractor, not an employee of the contractor. I do not want workers’

compensation insurance and understand that I am not eligible for Workers’ Compensation benefits;

4. I will obtain workers’ compensation and employers’ liability insurance for my employees if I have employees,
unless they are otherwise exempt from the requirements of the Workers’ Compensation Act;

5. I have read, signed and attached the Exempt Status Fact Sheet describing what is an Independent
Contractor and the information provided is not the result of force, threats, coercion, compulsion or duress;

6. I understand that the execution of the affidavit shall establish a rebuttable presumption that the executor is
not an employee for purposes of the Workers’ Compensation Act;

7. I understand that the execution of an affidavit shall not affect the rights or coverage of any employee of the
individual executing the affidavit.

IN WITNESS WHEREOF, we have hereunto set our hands this 4th day of June, 2018 at Diffun, Quirino.

ALFONSO U. DANTES II
Affiant

SUBSCRIBED AND SWORN to before me in the Municipality of Diffun this 4th day of
June, 2018.

Atty. MA. KAREN A. BALDONADO-GUILLERMO

Notary Public
Until December 31, 2019
Doc. No. 496; PTR No. 3218465/ 01-03-2018
Page No. 101 ; Lifetime IBP No. 17396/05-20-2017
Book No. 03; ROLL No. 67812/05-26-2017
Series of 2018. (MCLE Governing Board Order No. s-2008)
Diffun, Quirino