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C1 TY OF SA MrA A NA <br />Rii sK MANAGEMENT a d&wso o� HUMAN RESOURCES <br />M,anaglng RM vAnugh PoOdw 0unge <br />(D <br />la Karduz Nguyen/CE,O —__—hereby affirm under penalty of perjury, the <br />following declaration: <br />I certify on behalf of Vietnamese Language Access that during the term <br />(Ccnsultantl, .-.otnpany Nurne) <br />of my contract for speaker/performer - services with the City of Santa Ana, <br />(Type of service provided) <br />I will not ernpI:oy any person in any manner so as to become subject to the workers' <br />comipensation laws of California, and agree that if I shouId become subject to the <br />workers' comipensation 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 />Print Name: Karduz Nguyen <br />... . ... ......... . ...... .......... . . ............. <br />Print Title C... ......EO/Executive Director <br />Signature: <br />Telephone V <br />: 650-808-5121 <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 ($100,0001). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOiR IN SECTION 37016 OF THE LABOR CODE, INTEREST, AND ATTORNEYS FEES. <br />1:�R'isk Mgmt�lnsurance Requirements�WC Declorotion 081520.19 <br />RiskMm%vmvADWW= <br />j?� REVIEWED& APPRovED J!h- <br />Risk Management Analyst <br />