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CITY OF SANTA ANA <br />RISK MANAGEMENT, diu� 4HUMAN RESOURCES <br />Managing ft& dvouo Posidw Changi: <br />WORKERS' COMPENSATION DECLARATION <br />Cesar Vargas/Executive Director hereby affirm under penalty of perjury, the <br />(Nome/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: May 24, 2021 <br />Print Name: Cesar Vargas <br />Print Title <br />Signature <br />Telephone <br />Executive girector <br />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 />�.__� IURM�¢MflttUM9lprt <br />I:�Risk MgmtJ Insuran ce Re q uirem en ts ) WC Declaration 08152019 It. '" Fµ� k. VWA� <br />�. <br />Rlsk Management Analyst <br />