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I <br />CITY OF SANTA ANA <br />RiSR MANAGEMENT dkua"4HUMAN RESOURCES <br />Managing M* fft vgpA PodtWe ChanW <br />WORKERS' COMPENSATION DECLARATION <br />Barbara Heidenreich <br />(Name/Title) <br />following declaration: <br />hereby affirm.under penalty of perjury, the <br />I certify on behalf of Barbara's Force Free Animal Training DBA Good Blyd Inc that -during the term <br />(Consultan t/Compony:Ndme) <br />of my contract for Animal Training Consulting services with the City of Santa Ana_- <br />(Type of service provided) <br />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 the provisions and provide proof of workers' compensation coverage <br />immediately. <br />Date: 11 /19/2024 <br />Print Name: Barbara Heidenreich <br />Print Title: President <br />Signature: <br />Telephone: 12- 4'23-7734 <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS' UNLAWFUL, AND <br />SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED <br />THOUSAND DOLLARS ($100,000). IN ADDITION TO THE COST OF COMPENSATION, DAMAGES AS <br />PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE,`INTEREST, AND ATTORNEY'S FEES. <br />APPROVED <br />By Cynthia Mora at 5:09 pm, Dec 04, 2024 <br />I: )Risk Mgmt�Insurance RequirementsJWC Declaration 08152019 - <br />