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C)49 /& S!.4! A NA <br />R ISK M ANAGEMENT a division of H UMAN R ESOURCES <br /> <br /> <br /> <br /> <br />UipnbtS/Ipmmjnbo <br />I, _____________________________ hereby affirm under penalty of perjury, the <br /> ΛbğƒĻΉźƷƌĻΜ <br />following declaration: <br />U/S/IpmmjnboboeBttpdjbuft-Jod/ <br />I certify on behalf of _________________________________ that during the term <br /> Λ/ƚƓƭǒƌƷğƓƷΉ/ƚƒƦğƓǤ bğƒĻΜ <br />SfdzdmfeXbufsNbtufsQmboojoh <br />of my contract for ________________________ services with the City of Santa Ana, <br /> ˁǤƦĻ ƚŅ ƭĻƩǝźĭĻ ƦƩƚǝźķĻķΜ <br />compensation laws of California, and agree that if I should become subject to the <br />e Labor Code, I shall forthwith <br /> <br />immediately. <br />Date: <br /> <br />2032031 <br />Print Name: <br /> <br />UipnbtS/Ipmmjnbo <br />Print Title: <br /> <br />Qsftjefou0NbobhjohFohjoffs <br />Signature: <br /> <br />Telephone: <br /> <br />:1:.684.7913 <br />WARNING: 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 SECTIS. <br /> <br /> <br />Lʹ΍wźƭƉ aŭƒƷ΍LƓƭǒƩğƓĭĻ wĻƨǒźƩĻƒĻƓƷƭ΍‘/ 5ĻĭƌğƩğƷźƚƓ ЉБЊЎЋЉЊВ <br />