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WORKERS' COMPENSATION DECLARATION <br />I Samantha Waugh hereby affirm under penalty of perjury, the <br />(Name Tide) <br />following declaration: <br />I certify on behalf of _Samantha Waugh that during the term of my <br />(CowidmndCompany Na,,) <br />contract for Recreation Classes 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 />DATE: _ ] . 2� .1CA <br />By: <br />Name: CSa,w(rWCeU1a- ',tiLtl <br />Title: Recreation Instructor <br />Telephone: <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 />day <br />s <br />p\GC'Plp Sti�b© <br />D <br />tj /9, <br />