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WORKERS' COMPENSATION DECLARATION <br />I _Marisca M. Secundo hereby affirm under penalty of perjury, the <br />(Name'litle) <br />following declaration: <br />I certify on behalf of. Marisca M. Sectmdo that during the term of my <br />(Cais¢Itant 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 Sy: <br />Name: Marisca M. Secundo <br />Title: Dance Instructor <br />Telephone: 714-781- <br />6�`:� <br />�P' <br />a <br />WARNING: FAILURE E WORKERS' COMPENSATION COVERAGE IS <br />UNLAWFUL, AND SH` L SU JECT AN EMPLOYER TO CRIMINAL PENALTIES <br />