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C7TYGFSAN'rAAnA <br />PUSH NMANAGWENT a &� es HUMANRESOURCES <br />Affidavit of Exemption for Workers' Compensation Insurance <br />John M. Raya, rtaunder/president hereby affirm under penalty of perjury, the <br />(Nnmer7Cie) <br />following declaration: <br />I certify on behalf of TKO Youth Foundation i''°TKo'ri _ that during the term <br />jConsulcant/Cprnpnny NarmeJ <br />of my contract, for afterachool youth program services with the City of Santa Ana, <br />(Type of serZe prowded) <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.e <br />Print Narne:....a}C.Hr9 _r`i A <br />PrintTitde: M700 �R. <br />J- <br />Tele ha�ne.- f�.• �' a <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 />r.a,Rlsk Mgmt\lmuranee Requirements\ Affidavit o4 Ewemption For Workers' compensation Insurance 2021. <br />AfekMav�mrnfDh7dor� <br />„� g(�vIEWEo&ArHm�pV{mBY): <br />I"�LN�bs1.8 :F.' �nAfMML <br />= Rislc Mana9wnentAmlyS[ <br />