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WORKERS' COMPENSATION DECLARATION <br />[ Melina Herrera hereby affirm under penalty of perjury, the <br />(Namee-1itle i <br />following declaration <br />I certify on behalf of Melina Herrera that during the term of my <br />(Consultant Company \mne) <br />contract for _Recreation Classes services with the City of Santa <br />Ana, 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 those provisions and provide proof of workers' compensation coverage. C_p DATE: " !y' V <br />By: t_�,C� <br />Name: Melina Herrera <br />Title: Instructor <br />Telephone: _714 955-1979 <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 />�ev`eW ed by'. <br />�y <br />Guev as <br />PRGs �l �dm�n 5 <br />