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N-2018-169 <br />WORKERS' COMPENSATION DECLARATION <br />I Gloria Itzel Montiel hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />I certify on behalf of _Gloria Itzel Montiel_ that during the term of my <br />(Consultant/Company Name) <br />contract for _Memories of Migration Consulting Agreement_ services with the City of <br />Santa Ana, I will not employ any person in any manner so as to become subject to the <br />workers' compensation laws of California, and agree that if I should become subject to <br />the workers' compensation provisions of Section 3700 of the Labor Code, I shall <br />forthwith comply with those provisions and provide proof of workers' compensation <br />coverage. <br />DATE: August 27, 2018 <br />Name: Gloria Itzel Montiel <br />Title: Consultant <br />Telephone: _714-697-8119 <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 ATTO�Y'S FEES. <br />��\e� <br />