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1 Mike Elerick <br />(NamefTitle) <br />following declaration <br />hereby affirm under penalty of perjury, the <br />PIcertifyon behalfof <br />u l i c aft rr� <br />® that during the terns of my <br />Training (Consultant/Company Name) <br />contract forservices with the City of Santa Ana I will <br />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 those provisions and provide proof of workers' compensation coverage. <br />By: <br />Mike Elerick <br />Name:� <br />.rale: Executive Director <br />Telephone: 53O 906-5412 <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 />