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CITY OF SANTA ANA <br />RISK MANAGEMENT4HUMAN RESOURCES ����}.. <br />Managing Risk mvm�n Positive Change �g C��.�' <br />WORKERS' COMPENSATION DECLARATION <br />Katherina Sutter <br />(Name/Title) <br />following declaration: <br />hereby affirm under penalty of perjury, the <br />I certify on behalf of Katherina Sutter that during the term <br />(Consultant/Company Name) <br />of my contract for Music/ Dance education 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 1, 2023 <br />Print Name: Katherina Sutter <br />Print Title: Ms. <br />Signature: K.Gt��2eV/Na 1iGtl �2Y <br />Katherina Sutter iMay 1, 202312:54 PDT) <br />Telephone: 9492908985 <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 EwmM&MPRiw®8r <br />A.-PAow44 <br />Ruk Management Speddist <br />l: RiskMgmt�lnsurance RequirementsiWC Declaration 08152019 <br />