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W o,�IL�(�S Cpm �1nSCt4-�0� 1�2.C�CU'�0.'�Ofl <br />I _Marisca M. Secundo hereby affirm <br />under penalty of perjury, the <br />(Name/Title) <br />following declaration : <br />I certify on behalf of _ Marisca M. Secundo <br />that during the term of my <br />(Consultant/Company Name) <br />contract for _Recreation Classes <br />services with the City of Santa Ana, I will not employ any <br />person in any manner so as to become subject to the <br />workers' compensation laws of California, and agree that if <br />I should become subject to the workers' compensation <br />provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions and provide proof <br />of worker ' c mpet coverage. <br />DATE: <br />—,00? By: <br />Name: Marisca M. <br />Secundo <br />Title: Dance <br />Instructor <br />� Telephone: 714 781- <br />9017 �K'0 0ea 1 — <br />N <br />WARNING: FAILURErE <br />E WORKERS' <br />COMPENSATION C E UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL <br />PENALTIES AND CIVIL FINES UP TO ONE <br />HUNDRED THOUSAND DOLLARS ($100,000). IN <br />ADDITION TO THE COST OF COMPENSATION, <br />DAMAGES AS PROVIDED FOR IN SECTION 3706 OF <br />THE LABOR CODE, INTEREST, AND ATTORNEY'S <br />FEES. <br />