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CITY OFSANTA ANA ry <br />RISK MANAGEMENTa &Aaem gHUMAN RESOURCES <br />Managing . 000MA p nce <br />WORKERS' COMPENSATION DECLARATION <br />Cesar Vargas, Exec. Director hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Cesar Vargas & Associates/MENTE, Inc. that during the term <br />(Consultant/Company Name) <br />of my contract for Translation/interpretation � services with the City of Santa Ana, <br />(Type of service provided) <br />I will 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 the provisions and provide proof of workers' compensation coverage <br />immediately. <br />Date: November 12, 2020 <br />Print Name: Cesar Vargas <br />Print Title: Executive Director <br />Signature: 4- l/F� <br />Telephone: 714.987.2889 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />I tRisk M,gmt�lnsurance Requirements�WCDecloration 08152019 <br />� sn�> RiekMnnagtm�mtDividon <br />REVIEWED & APPR0vm BY., <br />Ru k Manatjement Analyrt <br />