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WORKERS' COMPENSATION DECLARATION <br />I _Karina Morales Ocampo hereby affirm under penalty of perjury, the <br />(NmwTiae) <br />following declaration <br />I certify on behalf of _ Karina Morales Ocampo _ that during the term of my <br />(Comu1w*ComWy Name) <br />contract for _Leisure Class Instruction _ services with the City of Santa Ana, I will <br />not employ any person in any manner so as to become subject to the workers' <br />compensation laws of California, and agree that if I should become subject to the <br />workers' compensation provisions of Section 3700 of the Labor Code, I shall forthwith <br />comply with those provisions and provide proof of workers' compensation coverage. <br />. <br />DATE: J 1 113)11'11 <br />By: . �, Aa__� <br />Name: _ arina Morales Oca(npo <br />Title: Leisure Class Instructor <br />Telephone: ( 14)944 -'r20ti5 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />