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Karduz Nguyen <br />CITYOFSANTAANA <br />RISK MANAGEMENT d4-aaaa 4HUMAN RESOURCES <br />Managing IMsh oftug,Positim Change 1 <br />WORKERS' COMPENSATION DECLARATION <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of VIETLA that during the term <br />(Consultant/Company Name) <br />of my contract for 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 />Date: 06/01/2023 <br />Print Name: <br />Karduz Nguyen <br />Print Title: CEO <br />Signature: <br />Telephone: <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 ($100,000). IN ADDITIONAL TO THE COST OF COMPENSATION, DAMAGES <br />AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />l: Risk Mgmt�lnsurance Requirements� WC Declaration 08152019 <br />_ RlekMnugenantDlvieiun <br />sry �n`^• "� REVIEWED 6 APPROVED Br. <br />A+� Auwrlo <br />Risk Managemem Specialist <br />