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CITY OF SANTA ANA <br />RISK MANAGEMENT a dtutae" 4 HUMAN RESOURCES _ <br />Managing Risk n„nugn Poshtye Change <br />WORKERS' COMPENSATION DECLARATION <br />I, Yenny R. Bernal de Talmo hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Uplifting Soul Art Events that during the term <br />(Consultant/Company Name) <br />of my contract for Investing in the arts Grant Fiesta de Cultural 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: 07/30/2024 <br />Print Name: Yenny R Bernal de Talmo <br />Print Title: Sole Proprietor <br />Signature: loot <br />Telephone: <br />949/545-1666 <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 />/ lRssk Mgmt�lnsurance Requirements�WC Declaration 08152019 <br />77.1 <br />n"y <br />RmkMougemadDWmt <br />REMEWM&AWRMMSY. <br />A,A <br />RM Management Spedahst <br />