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WORKERS' COMPENSATION DECLARATION <br />Chuong T. Bui hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of <br />that during the term of my <br />(Organization Name) <br />contract with the Community Development Agency, City of Santa Ana, I will not employ <br />Counsel for Creators LLP <br />any person in any manner so as to become subject to the workers' compensation laws of <br />California, and agree that if I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall forthwith comply with those <br />provisions. <br />DATE: 8/27/19 <br />By: <br />Name: Chuong T. Bui, Esq. <br />Title: Partner <br />Telephone: <br />213-379-9697 <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 />REVIEWED & APPROVED <br />By RISK MANAGn EMENT NISION <br />,27219 <br />FRANC E R. VILLAREAL <br />