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WORKERS' COMPENSATION DECLARATION <br />I —Marisca M. Secundo hereby affirm under penalty of perjury, the <br />(Name'Title) <br />following declaration: <br />I certify on behalf of Marisca M. Secundo that during the terms of my <br />(Consultant/Company Name) <br />contract for Recreation Classes services with the 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 and provide prorrof of workers' compensation coverage. <br />DATE: 3-20-17 <br />9017 <br />Signed By: <br />Name: Marisca M. Secundo <br />Title- Dance Instructor <br />Telephone: <br />C-1 <br />714-781- <br />WARNING: FAILUREEnEC NSATION COVERAGE IS <br />,,�WORKERS'COMPE <br />UNLAWFUL, AND S LL SU fr-CT AN EMPLOYER TO CRIMINAL PENALTIES <br />