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WORKERS' COMPENSATION DECLARATION <br />I Jason Lee/Ceo hereby affirm under penalty of perjury, the <br />(Name/Title) <br />following declaration <br />I certify on behalf of Hierarch Academy that during the term of my <br />(Organization Name) <br />contract with the Santa Ana workforce City of Santa Ana, I will not <br />employ any person in any manner so as to become subject to the workers' compensation <br />laws of California, and agree that if I should become subject to the workers' <br />compensation provisions of Section 3700 of the Labor Code, I shall forthwith comply <br />with those provisions. <br />DATE: 5/9/23 <br />Jason Lee <br />` .� <br />Title: Ceo <br />Telephone: <br />714 864 2801 <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). 1N <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 />