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WORKERS' COMPENSATION DECLARATION <br />I Gustavo J. Romo, CEO/Principal— hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration: <br />I certify on behalf of Romo Planning Group Inc. that during the term of my <br />(Organization Name) <br />contract with the City of Santa Ana, I will not employ any person in any manner so as to <br />become subject to the workers' compensation laws of California, and agree that if I <br />should become subject to the workers' compensation provisions of Section 3700 of the <br />Labor Code, I shall forthwith comply with those provisions. <br />DATE: October 14, 2008 <br />M. <br />Name: Gustavo J. Romo <br />Title: CEO/Principal <br />Telephone: (626) 926-1901 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES <br />AND CIVIL FINES UP TO ONE HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, DAMAGES AS PROVIDED FOR <br />IN SECTION 3706 OF THE LABOR CODE, INTEREST, AND ATTORNEY'S FEES. <br />�I�I,ROei }:l� AS TO FORM <br />A;�istant Litt' ?�ttorn�y <br />