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I, <br />C/TY OF SANTA ANA <br />RISK MANAGEMENT. d[atal" 4HUMAN RESOURCES <br />Managing Rik vywp* Pa0w Change <br />I-------- a <br />WORKERS' COMPENSATION DECLARATION <br />Barbara Heidenreich <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Good Bird Inc <br />that during the term <br />(Consultant/Company Name) <br />of my contract for Animal Training Consulting 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: 04/22/2022 <br />Print Name: Barbara Heidenreich <br />Print Title: President <br />Signature: <br />Telephone: 12-423-7734 • <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 />klRisk Mgmtllnsurance Requirements�WC Declaration 08152019 <br />.oa. <br />IUekM¢nagenlatlDhidon <br />REVIEWED 6 APPROVED BY. <br />A4V* &W44 <br />RBA Management Specials[ <br />