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SIGUENZA, HERBERT
INSUP,INCE ON �IMF N-2026-206 AUG 12 2926, (a), ARTS AND CULTURE ARTIST GRANT PROGRAM AGREEMENT BETWEEN o �Ur -.. i u (DZ-1 THE CITY OF SANTA ANA AND HERBERT SIGUENZA This Artist Grant Agreement ("Agreement") is made and entered this 1st day of June, 2026, by and between the City of Santa Ana, a charter City and municipal corporation organized and existing under the Constitution and laws of the State of California ("City"), and Herbert Siguenza ("Grantee")for the purpose of providing grant funding pursuant to the Investing in the Artist Grant Program. City and Grantee may herein individually be referred to as a "Party" and collectively be referred to as the "Parties" to the Agreement. RECITALS: A. On April 19th, 2026, the Arts and Culture Commission reviewed all applicants and recommended that Grantee be awarded an artist grant based on its Application for its art project ("Project"). A true and correct copy of Grantee's Application is attached hereto as Exhibit A and incorporated herein by reference. B. In undertaking the performance pursuant to this Agreement, Grantee represents that it is skilled and knowledgeable in the arts and culture arena and that the Project created or performed hereunder will be created or performed in compliance with such standards as may reasonably be expected from an artist. NOW THEREFORE, in consideration of the mutual and respective promises, and subject to the terms and conditions hereinafter set forth, the Parties agree as follows: 1. Term. This Agreement shall be effective upon signature by both Parties and shall expire one year from the date first written above, unless terminated earlier in accordance with this Agreement. 2. Funding. 2.1. Subject to Grantee's performance of all required actions under this Agreement, City shall provide funding, in three disbursements, as detailed below, of an amount not to exceed Five Thousand, Six Hundred, Eight-Six Dollars ($5,686) ("Grant Amount" or "Grant"). 2.2. Grantee will be paid in three (3) installments. First payment will be one-third of the funding amount provided above or $1,895.33 and will be provided within thirty (30) days of the full execution of the Agreement by the Parties along with a complete invoice submitted by Grantee. The second payment will be the second one-third of the funding amount provided above or $1,895.34 and will be provided within thirty (30) days after the Grantee submits to the City all the proper receipts and invoices up to the mid-point of the Project. The third and final payment will include the remaining amount of $1,895.33 and will be issued within thirty (30) days after the Grantee submits to the City all the proper receipts, invoices, and final report for the Project. 2.3. Appropriate performance of the Grantee will be determined by City in its sole discretion. City reserves the right to cease funding after the first or second disbursement detailed above, and to be reimbursed the initial payment(s), if Grantee's performance is determined to be insufficient or unacceptable in the City's sole discretion, 2.3. City represents that there is no correlation or connection between its selection of individuals for grant awards and an individual's business relationship or potential business relationship with City. 1 3. Grant Activities. Grantee agrees: 3.1. To perform the activities described in Grantee's Grant Application submitted to City for consideration dated March 24, 2026, a copy of which is attached as Exhibit A and incorporated into this Agreement as if set out in full. 3.2. To submit all reports (each, a "Report"), which shall include, at a minimum, the items set forth as required by the Application. No personally identifiable information shall be included in any of the Reports, except where specifically requested. The Reports shall be in a format that is reasonably acceptable to City. City may request additional information as City, in its sole discretion, determines is necessary to monitor performance of this Agreement. City shall have the right to use any Reports submitted by Grantee, or any portion thereof, for any reason. 3.3. To maintain all pertinent financial and accounting records pertaining to this Agreement in accordance with generally accepted accounting principles and other procedures reasonably specified by City. Upon termination or expiration of this Agreement or request by City, Grantee shall provide, at its expense, copies of all financial and accounting records produced by Grantee arising out of this Agreement. 3.4. To allow audits, compliance or special reviews and inspections, including on-site inspection, with or without prior notice, of Grantee's facilities by City or by third parties designated by City, or their authorized representatives. Grantee shall provide its full cooperation for any such audit, review or inspection, including providing timely access, for examination and copying of records (including computerized records) pertinent books, documents, papers, computer programs and records and reasonable access to its personnel. 3.5. To ensure that any areas utilized for the Project are maintained and restored to a well- maintained, safe, sanitary, and clean condition, and kept free of any hazardous waste at all times. All equipment associated with the installation of the artwork, trash and debris shall be removed and cleaned up on a daily basis. If applicable to the Project, Grantee shall place a drop cloth or similar barrier on the ground below the artwork while installation is underway, which barrier shall be removed each day upon completion of an installation session. 3.6. The Project may not contain advertising, religious art, sexual content, negative or violent imagery, convey political partisanship or include any hidden, subliminal, or camouflaged messages or statements of any kind or nature. Appropriateness of the content of the Project will be determined by City in its sole discretion. 3.7. The Project may not include any breach of intellectual property, trademarks, brands, or images of illegal activity, and the Grantee must be the copyright holder for the Project. It is the sole responsibility of the Grantee to obtain any and all applicable copyrights or trademarks associated with the artwork for the Project. 3.8. To be responsible for the maintenance of the Project, which includes, but is not limited to, graffiti removal, touch-up, and restoration, for the duration of the Project's existence. 3.9. If the artwork is a mural, it must be covered in an anti-graffiti coating at the Grantee's expense. 3.10. The City holds all rights to public art on City property, and as such the Project artwork may be removed at the sole discretion of the City. Should the Project artwork be defaced and/or not repaired, maintained, preserved and/or conserved, the City has the authority to repair, maintain, preserve, and/or conserve the Project artwork, or alternatively, the City has the sole authority to 2 remove, alter, or destroy the Project artwork. Grantee will have first right of refusal to restore said Project artwork. If Grantee is unwilling to perform or unable to be contacted within a reasonable time, the City has the right to request the services needed from a different artist, in the City's sole discretion. 3.11. Grantee shall execute and deliver to City any instruments that City may reasonably require to confirm ownership of any artwork. 3.12. Grantee shall be responsible for complying with all Federal, State, and local laws, ordinances, statues and regulations, including, but not limited to zoning and other environmental requirements (if applicable), and for obtaining all required licenses, permits, or other authorizations applicable to the performance of Grantee's Project under this Agreement. 3.13. The estimated dates of completion and proposed Project locations contained in he Grantee Application, Exhibit A, are just that, estimates and proposals, as they were provided to the Arts & Culture Commission. It is the responsibility of the Grantee to secure all necessary permits, approvals, location confirmation, facilities confirmation, from the appropriate entities, City departments or City facilities for the use of the proposed site for the Project. Execution of this Agreement does not guarantee any specific City permit, City location, or City site for the Project. 4. Termination. 4.1. City may immediately terminate this Agreement upon one or more of the following: 4.1.1. Grantee's violation of any federal, state or local law or regulation. 4.1.2. Grantee's.breach of any of the terms or conditions of this Agreement, including the Application, or any unapproved deviation from said documents that has not been cured within 30 days of written notice of such breach. 4.1.3. Grantee's failure to provide the documents to the City, as requested by the City by a date no later than three (3) months from the date of this Agreement, in order to maintain compliance with the Grant Program, City Policies or Procedures, or this Agreement. Such paperwork can include but is not limited to, completed vendor forms (City's administrative forms, IRS W-9 form, ACH payment forms), proof of insurance, and signed orientation paperwork. 4.2. In the event the Agreement is terminated under Section 4.1, City reserves the right to require Grantee to refund any or all grant funds awarded to Grantee under this Agreement, and Grantee agrees to refund to City any or all grant funds awarded under this Agreement. 5. Limitation of Liability. 5.1. IN NO EVENT SHALL CITY BE LIABLE FOR ANY INDIRECT, SPECIAL, INCIDENTAL OR CONSEQUENTIAL DAMAGES OR EXPENSES FOR ANY NEGLIGENCE, BREACH OF CONTRACT OR ANY OTHER ACT ARISING OUT OF OR RELATING TO THIS AGREEMENT OR THE ACTIVITIES COVERED HEREUNDER. 5.2. Section 5 and Section 6 do not limit Grantee's rights, including its ability to seek recovery, against anyone other than City, its City Council, officials, directors, officers, employees, agents, successors, assigns and volunteers. 3 6. Indemnification. 6.1. Grantee shall defend, indemnify, protect and hold harmless the City, and its City Council, elected and appointed officials and officers, employees, members, volunteers, or agents from and against all claims for damages, liability, cost and expense (including without limitation attorney's fees) arising out of or alleged by third parties to be the result of the negligent acts, errors or omissions or the willful misconduct of the Grantee, and Grantee's employees, subcontractors or other persons, agencies or firms for whom Grantee is legally responsible in connection with the execution of the work covered by this Agreement. Grantee shall have no duty to indemnify or hold harmless the City if claims, damages, liability, costs, expenses (including without limitation, attorney's fees) arise from the sole negligence or sole willful misconduct of the City subsequent to declaration by the Grantee. Grantee's obligations shall survive the termination of this Agreement. 6.2. Grantee agrees to hereby fully release and forever discharge the City from any and all claims, demands, damages, losses, and liabilities (hereinafter collectively referred to as "claims"), which are or may be related to or in any way connected with the negligence or willful misconduct of its officers, officials, employees, or agents in connection with the creation, painting, performance or installation of the Project hereunder. - 6.3. Grantee further agrees that City may in good faith and on reasonable terms settle any such claims and that City's right to indemnification shall extend to any such settlement, provided City has given notice of such claim and its intent to settle. City's right to indemnification is in addition to, and may be exercised independently of, any remedy held by City under this Agreement, at law or in equity. The indemnity provision set forth in this Agreement shall survive the termination or expiration of this Agreement indefinitely. 7. Insurance 7.1 Prior to undertaking performance of work under this Agreement, Grantee shall maintain and shall require its subcontractors, if any, to obtain and maintain insurance as described below: MINIMUM SCOPE AND LIMIT OF INSURANCE Grantee shall maintain limits of insurance coverage in the following minimum amounts and shall be at least as broad as: • Commercial General Liability(CGL): Insurance Services Office Form CG 00 01 covering CGL on an "occurrence" basis, including products and completed operations, property damage, bodily injury and personal &advertising injury with limits no less than $1,000,000 per occurrence and $2,000,000 aggregate. • Automobile Liability (AL): Insurance Services Office Form CA 00 01 covering Code 1 (any auto), with combined single limits of $1,000,000. In the event Grantee does not maintain commercial automobile liability insurance, City will accept evidence of personal automobile insurance with existing limits, which can be lower than $1,000,000. • Workers' Compensation (WIC): as required by the State of California, with statutory limits, and Employer's Liability Insurance with limit of no less than $1,000,000 per accident, per employee, per policy for bodily injury or disease. This requirement can be waived if Grantee has no employees. 4 If Grantee maintains broader coverage and/or higher limits than the minimums shown above, City requires and shall be entitled to the broader coverage and/or the higher limits maintained by Grantee. Any available insurance proceeds in excess of the specified minimum limits of insurance and coverage shall be available to City. Other Insurance Provisions The insurance policies are to contain, or be endorsed to contain, the following provisions: 1. CGL and AL policies: City of Santa Ana, its City Council, its officers, officials, employees, agents, and volunteers are to be covered as additional insureds with respect to liability arising out of work or operations performed by or on behalf of the Grantee including materials, parts, equipment, and personnel furnished in connection with such work or operations. 2. All required insurance policies: Insurance company(ies) agrees to waive all rights of subrogation against City, its City Council, its officers, officials, employees, agents, and volunteers for losses paid under the terms of any policy which arise from work performed by Grantee for City. 3. All required insurance policies: For any claims related to this contract, Grantee's insurance coverage shall be primary and any insurance maintained by City, its City Council, its officers, officials, employees, agents, or volunteers shall not contribute with it. 4. All required insurance policies: A severability of interest provision must apply for all the additional insureds, ensuring that Grantee's insurance shall apply separately to each insured against whom a claim is made or suit is brought, except with respect to the insurer's limits of liability. 5. Each insurance policy required herein shall provide that coverage shall not be - canceled, suspended, voided, reduced in coverage or in limits, non-renewed by the carrier, or materially changed except after thirty(30) days prior written notice has been given to City. Ten (10) days prior written shall be provided to City for policy cancellation or non-renewal due to non-payment. 0. Certificate Holder on each Evidence of Insurance certificate shall be: City of Santa Ana, Attention: Executive Director, Community Development Agency, 20 Civic Center Plaza M-25, Santa Ana, CA 92701. The name and location of event should be included in the Description of Operations section of each certificate. Acceptability of Insurers Insurance is to be placed with insurers authorized to conduct business in the state of California with a current A.M. Best rating of no less than A:VII, unless otherwise acceptable to City. Verification of Coverage Grantee shall furnish City with original Certificates of Insurance including all required amendatory endorsements (or copies of the applicable policy language effecting coverage required by this clause)and a copy of the Declarations and Endorsement Page of the CGL policy listing all policy endorsements to City before work begins. However, failure to obtain the required documents prior to the work beginning shall not waive Grantee's obligation to provide them. City reserves the right to require complete, certified copies of all required insurance policies, including endorsements required by these specifications, at any time. 5 Subcontractors Grantee shall require and verify that all sub-contractors maintain insurance meeting all the requirements stated herein, and Grantee shall ensure that City is an additional insured on insurance required from sub-contractors. Special Risks or Circumstances City reserves the right to modify these requirements, including limits, based on the nature of the risk, prior experience, insurer, coverage, or other special circumstances. 8. General Provisions. 8.1. Grantee shall acquire prior written permission from City for any use of the City name or logo in association with the Project. 8.2. If any parts of this Agreement are held to be invalid or unenforceable, the remaining parts of the Agreement shall continue to be valid and enforceable. 8.3. Grantee shall comply with all governmental requirements that may now or in the future become applicable to the activities under this Agreement. 8.4, This Agreement, including all exhibits, Application, and any amendments or schedules hereto, contain the full understanding and agreement of the Parties with respect to its subject matter, and no waiver, alteration or modification of any of the provisions to this Agreement shall be binding unless in writing and signed by an authorized officer of both Parties. 8.5. No waiver by either Party or any breach, default, or series of breaches or defaults, and no failure, refusal, or neglect of either Party to exercise any right, power, or option given to it under this Agreement or to insist upon strict compliance with the terms of this Agreement shall constitute a waiver of these provisions with respect to any subsequent breach or waiver by either Party or its right at any time thereafter to require exact and strict compliance with provisions of this Agreement. 8.6. Any notice or other communication required or permitted to be made or given by either Party pursuant to this Agreement will be in writing and will be deemed to have been duly given: (i)five (5) business days after the date of mailing if sent by registered or certified U.S. mail, postage prepaid, with return receipt requested; (ii) when transmitted if sent by facsimile, provided a confirmation of transmission is produced by the sending machine; or (iii) when delivered if delivered personally or sent by express courier service.All notices to City shall include a reference to the Project title. All notices will be sent to the other Party at its address as set forth below or at such other address as such Party will have specified in a notice given in accordance with this section: Grantee: Herbert Siguenza 3943 Polack St San Diego, CA 92110 City: City of Santa Ana City Clerk (M-30) 6 20 Civic Center Plaza P.O. Box 1988 Santa Ana, CA 92702 FAX (714) 647-6956 8.7. This Agreement is subject to all applicable local, State and Federal laws. This Agreement has been executed and delivered in the State of California and the validity, interpretation, performance, and enforcement of any of the clauses of this Agreement shall be determined and governed by the laws of the State of California. Both Parties further agree that Orange County, California, shall be the venue for any action or proceeding that may be brought or arise out of, in connection with or by reason of this Agreement. 8.8. Grantee agrees to comply with all applicable equal opportunity and affirmative action laws as appropriate, Grantee shall not discriminate because of race, color, religion, sex, gender identity, gender expression, marital status, sexual orientation, age, national origin, ancestry, medical condition, military or veteran status, genetic information, request for family care leave, request for leave for an employee's own serious health condition, request for pregnancy disability leave, disability, or otherwise as defined and prohibited by applicable law, in the recruitment, selection, training, utilization, promotion, termination or other employment related activities. Grantee affirms that it is an equal opportunity employer(if applicable) and shall comply with all applicable federal, state and local laws and regulations. 8.9. Any funds provided under this Agreement that are not expended, obligated or otherwise committed by the termination or expiration of this Agreement shall be immediately returned to City. 8.10. Grantee grants to City a non-exclusive, irrevocable, transferable, royalty free, worldwide license to use, reproduce, display, distribute, and prepare derivative works, in any form or media at the discretion of the City for the Project conceived, performed or created as a result of this Agreement. 8.11. Grantee and any of the Grantee's agents, employees or representatives are,for all purposes under this Agreement, an independent contractor and shall not be deemed to be an employee of the City, and none of them shall be entitled to any benefits to which City employees are entitled including but not limited to, overtime, retirement benefits, work's compensation benefits, injury leave or other leave benefits. 8.12. Neither Party shall assign any rights or obligations Under this Agreement. 8.13. Each Party covenants that it presently has no interests and shall not have interests, direct or indirect, which would conflict in any manner with performance of services specified under this Agreement. 8.14. Each Party warrants that they have executed this Agreement knowingly, freely and voluntarily and with full knowledge of its legal consequences. All Parties involved warrant and represent that, prior to executing this Agreement, each Party has had the opportunity to review and consider this matter with legal counsel, and that the terms of this Agreement, and its consequences, are fully understood by each Party. 7 8.15. This Agreement represents the entire agreement and understanding between the Parties, and supersedes any and all prior agreements and understandings between the Parties, whether oral or written. 8.16. Each undersigned represents and warrants that its signature herein below has the power, authority and right to bind their respective Parties to each of the terms of this Agreement, and shall indemnify City fully, including reasonable costs and attorney's fees, for any injuries or damages to City in the event that such authority or power is not, in fact, held by the signatory or is withdrawn. {Signatures on following page} 8 IN WITNESS WHEREOF, the Parties hereto have executed this Agreement the date and year first above written. ATTEST: CITY OF SANTA ANA JENNIF L. AL W f, ALVARO NUNEZ City Cl City Manager APPROVED AS TO FORM: GRANTEE: SONIA R. CARVALHO City Attorney y. Andrea N. Ga ci 4Name: ert Si enza Senior Assistant City Attorney Title: Artist RECOMMENDED FOR APPROVAL: G� MICHAEL L. GARCIA Executive Director Community Development Agency 9 EXHIBIT A INFESTING IN THE ARTS GRANT PROGRAM APPLICATION 10 City of Santa Ana Powered by Submiffable, Title 0009 03/24/2026 by Herbert Siguenza in Investing in the Artist id. 53610653 2025-2026 - Individual Artist 3943 Polack San Diego, California 92110 CA United States 818-403-1384 siguenzaherbert@gmail.com Original Submission 03124/2026 Score S1 .............. --------- Name of Applicant Herbert SigUenza ---------- ................ Address of 3943 Polack St. Residence San Diego California 92110 us Mailing Address (if applicable) Email siguenzaher'bert@gmaii.com ............ ......................... Phone Number +18184031384 Website, other social https://www.ser.org/scr-blog/posts/a-role-he-was-born-to-.play/ media (if applicable) ----------- Category of Art Other (Check all that apply) Film Performing Visual Music Literary If"other" art category Other categories include Comedy, Documentary Theatre and Digital (enter name or N/A) Storytelling. The project is multidisciplinary. It will require research, writing, planning, producing, acting and editing video. Brief Description of "Viva Santa Ana!" is an original 25-minute comedy television show written, Project produced, filmed, performed and edited by Santa Ana residents. The program will look and feel like a classic local-interest TV show, featuring lively hosts, guest interviews, and on-site human-interest segments exploring the people, culture, and everyday life of the city. Comedic and satirical in tone, the show playfully highlights and skewers the triumphs, contradictions, and challenges familiar to the community. The workshop and production will be led by award-winning 40-year TV, stage and film comedy veteran Herbert Siguenza, a founding member of the legendary Latino performance troupe Culture Clash. Full Description of Project Viva_Santa_Ana_1.pdf Type of Application: Artist does not live or work in Santa Ana and proposes 100% of grant funds for a project based in Santa Ana Proof of live/work in Santa Ana Ward of Project Ward 1 (Check all that apply) Ward 2 Ward 3 Ward 4 Ward 5 Ward 6 Amount Requested 10000 (up to $10,000) If approved, you may Full funding of $10,000 will allow the project to achieve the level of quality, not receive the total community engagement and polish needed to create the look, feel and amount you are content of a real local television show that captures Santa Ana's culture, requesting, please be spirit and identity. The funds will support in-person classes and time for prepared to have development, production, and post-production, ensuring a well-crafted, other funding funny and engaging final program, sources and/or scale The full amount will also allow project lead Herbert Siguenza to travel and down your project. spend more in-person time in Santa Ana with the resident creative team as How will this impact they write, rehearse, and produce the show. Funding will make it possible your project (where to compensate local guest actors for their contributions and to hire would you get more experienced editors who specialize in comedic timing, video transitions, funding and/or how music and graphics. Funds will cover essential production elements such would you scale as props and costumes. This project will also connect Herbert with Santa down your project)? Ana College and SAUSD to organize presentations to Santa Ana students. We have secured $6,600 of project support from Media Arts Santa Ana and in-kind services for project expenses beyond the $10,000 requested from this grant. While the project could be completed with less funding, this could reduce the number of classes, the duration of the project and the engagement with the local community, Full funding would enable the level of engagement knowledge sharing and resource sharing that would give Santa Ana participants a unique bootcamp that provides professional and artistic training and experience, as well as networking opportunities and career development provided by Mr. SigOenza. This can lead to references, connections and career advice that could have a transformational effect on the lives of the participating artists and the Santa Ana community. If we do not receive the full amount of funding, we can seek other grant sources and conduct local fundraising performances and screenings and discussions of Mr. Sig0enza's films A Weekend with Pablo Picasso, 57 Chevy and The Culture Clash Show. We can also host public readings and signings of Herbert's new book, Anthology of New Plays. El Henry & 5 others. Full funding would allow free public screenings and discussions to increase Herbert's engagement with the local community. There is a strong individual need for funding from this grant to conduct this project in Santa Ana. Have you/will you be No receiving funding from the City within the fiscal years 200-2025? (include Special Events Sponsorship, Utility Box Art, etc.) If YES, list: 1) NIA Program Name, 2) Year, 3) Amount. [Ex: Utility Box Art, 2020, $450] Project fulfills the Foster a citywide culture of equity, inclusion, and access. following goal(s) from Support and expand arts and cultural programming to engage all the Arts & Culture populations (regardless of age, gender, ethnicity, backgrounds, or Master Plan (check socioeconomic status) throughout the community. all that apply). Support existing and create new opportunities for youth to engage in artistic and creative activities and career pathways. Identify community spaces for artistic and creative collaborations and create a roadmap for new cultural facility development through City and organizational partnerships. Preserve Santa Ana's unique heritage while creating arts and culture opportunities through placemaking initiatives. Create visible and interactive arts opportunities for engagement through public art. Contribute to the economic growth of the City, including development of a skilled workforce. Artist Resume/CV Herbert—Siiguenza_Bio_and_Resume_Santa_Ana.pd# Narrative for PROJECT TIMELINE AND BUDGET NARRATIVE proposed use of "Viva Santa Ana!" will be produced in the style of a local community funds: television program. The project will be organized into-collaborative teams and structured phases to achieve our goal: to produce a 25-minute comedic mock community TV program that will ultimately be distributed online. Funds will be used for Herbert Sig0enza's artist fee, a professional editor, stipends for local actors, equipment, space rental, insurance and funds for the video premiere and community celebration at the end of the project. Additional support has been secured for a project assistant, video/documentation/tech professional, advertising/outreach and printing. WRITING AND DEVELOPMENT PHASE September— November 2026 The first three months will focus on learning and practicing the craft of short-form comedic writing. A cohort of 10-12 participants will meet weekly to research local issues, events, and stories from Santa Ana and develop them into comedic sketches and mock news segments for the program. All sketches will be reviewed, discussed, and refined collaboratively by the writing team during weekly in-person sessions at Media Arts Santa Ana (MASH). Project leader Herbert Siguenza will travel from San Diego to facilitate these writing workshops and guide the creative process. His responsibilities include leading the writing sessions, directing the production phase, and overseeing completion of the final program by May 2027. Project Leader Fee: $6,000 Space Rental: $1,000 SCRIPT DEVELOPMENT AND PRE-PRODUCTION December 2026 During December, the team will continue refining scripts through follow-up Zoom meetings to finalize sketches and prepare them for production. Casting and Production Planning January 2027 This phase will focus on casting local actors and identifying filming locations, Writers will also have the option to perform in the production if they choose. Budget allocations include: Actor stipends: $1,000 ($100 for up to 10 actors) Costumes and props: $250 FILMING PHASE February— March 2027 Weekend filming sessions will take place throughout February and March to capture all scenes for the program. Production will rely primarily on iPhones and personal video cameras, maintaining the aesthetic of a grassroots community television show. However, to ensure quality sound and lighting, additional equipment will be - purchased and/or rented, including a Lumix full frame hybrid video camera. Production expenses include: Sound and lighting equipment purchase: $700 Equipment rental: $300 Water and snacks for cast and crew during filming: $250 POST-PRODUCTION April 2027 By April, all filming will be completed, and the project will move into the editing phase. The writing team will provide creative input while a professional editor assembles the final program and adds finishing touches. Post-production will include video editing, sound balancing, voice-over recording, and graphic elements. Editor Fee: $1,000 COMMUNITY PREMIERE AND ONLINE RELEASE May 2027 The completed program will premiere at Media Arts Santa Ana (MASA). The event will invite members of the Santa Ana and Orange County community to attend a public screening on a large video screen, followed by a question-and-answer session with the creative team. A modest reception will be held afterward in the gallery space. Reception Budget: $500 (food and refreshments) The following day, "Viva Santa Ana!"will be released on YouTube, making the program accessible to a worldwide audience. Supplemental "Viva Santa Anal"will not require any permits or licenses while in Question 1: Please production. Most of our shoots will be interiors. We will use "green screen," describe any backdrops to reproduce any kind of set or backdrop in editing. We will use additional City of the rooms and facilities at MASA(Media Arts Santa Ana) for many of the Santa Ana resources indoor shots, including their 30-foot long green screen. The participants will required for your propose shooting locations available to them, such as homes or project (permits, businesses, and we will also scout local locations based on the segments public space, developed by the participants. The production team will be self-sufficient licenses etc.) that and adaptable to any situation or problem that may arise. you are required to obtain? Where will the MASNs TVGB Digital Maker Space, 1666 N Main, Santa Ana, CA 92701 project/program be located (give exact address, if possible)? Letter/Email from Property Owner (for public art installations, use of city parks, use of city parklets) Supplemental This is a new project. This project represents the first time I will be Question 2: Is this a conducting a workshop in Santa Ana, and the first time this unique and fun new or existing project will be offered in Orange County. Media Arts Santa Ana (MASA) is program/project? providing support for this project and will seek funding support to continue it as part of their many community arts classes in the future. ,"Viva Santa Ana!" is a starting point of a very exciting program that teaches interdisciplinary skills, creative and professional development to local participants and brings them important networking, mentoring opportunities with a nationally-respected award-winning Latinx comedy pioneer. Supplemental The Viva Santa Ana! project will be shared with the public in a number of (question 3: How will ways. It will be promoted via project community partner Media Arts Santa the proposed project Ana's extensive email list that includes local artists, educators, arts be presented or organizations, neighborhood associations, city officials and staff, SAUSD's shared with the Family and Community Engagement (FACE) liaisons, and residents of the public? Will the art Santa Ana Arts Collective building. Fliers will also be distributed throughout display, event or Santa Ana, including downtown Santa Ana, coffee shops, bookstores, performance be free Santa Ana College, locations on Main Street, to Santa Ana College, and accessible to the SAUSD and OCSA drama teachers and more. Examples of fliering public? locations include the Frida Cinema, 4th Street Market, CafeCito, CervezaCito, Corazon Cafe, Delhi Center, the Santa Ana Arts Collective and the Santa Ana Library. We will also place 1=acebook ads and create events in Facebook and Eventbrite. The classes will be free and accessible to the public. We will also reach out to SAUSD and SAC drama teachers to interest them in Herbert presenting to their classes. The completed "Viva Santa Anal" program will have a community viewing PREMIERE at Media Arts Santa Ana's (MASH) TVGB Digital Maker Space, located at 1666 N Main, in May of 2027. Participants and their families will be invited, as well as the community at large. After the screening, we will have a question-and- answer session with all the participants and creators. A post-premiere reception will follow. The next day, the show will be available to watch and enjoy WORLDWIDE by posting it publicly on YouTube and MASA's website. Supplemental The Santa Ana residents who will participate in the creation and production Question 4: How will of Viva Santa Ana!-will be enriched in several ways.. A real or mock TV this project enrich the show takes TEAMWORK to make it a reality. The project will rely on first- quality of life for time WRITERS who will research and develop sketches and situations Santa Ana specific to the city of Santa Ana and the Orange County area. Professional residents? and first-time ACTORS will lend their talents to create a comedic world. This project will be handled like a professional production, and the participants will gain real-world producing experience. The production will be hilarious for EVERYONE to enjoy watching on YouTube or private screenings. Comedy is a social salve that unifies and enriches people's lives if only for a few moments. It's a collective experience. Herbert Sig0enza is bilingual and the class will be accessible and valuable to Santa Ana's large Spanish-speaking population. Herbert will be working with Creative Capital award-winning multidisciplinary artists and Media Arts Santa Ana Co-Founders Victor Payan and Pocha Pena to work with participants to tailor their visions to the Santa Ana experience and community. Payan and Pocha are known for their own comedic approach to addressing community issues, and this project marks the first time Herbert, Victor and Pocha will be collaborating on a project. Another way this project will enrich the quality of life for Santa Ana residents is that it also serves as a bootcamp for participants to pick Herbert's brain about professional aspects of the arts & entertainment industry. Supplemental This project will stimulate economic development in Santa Ana in a number Question 5: Describe of ways. First, bringing Herbert SigGenza to Santa Ana for an extended how your project will period of time will providing Santa Ana residents with a unique opportunity stimulate economic to learn, network, socialize and even become friends with one of the development for the nation's most revered Latinx theatre artists. Class participants will receive City of Santa Ana. personal access to a wealth of professional experience, wisdom and advice, such as: How to prepare and audition for a role? What other classes should I take or what books should 1 read to direct my career path? How do I get an agent? Herbert is well-known in the Orange County arts and theatre communities, and he can serve as a connector between Santa Ana theatre artists and organizations such as South Coast Repertory, the Los Angeles Theatre Centre and drama programs and departments. Herbert can also provide letters of recommendations to participants who complete the program for applications, job interviews, etc. Having Herbert in Santa Ana for an extended period of time as a creative and professional resource would have life-changing impact on the careers and income potential of participants. Additionally, this project would provide Santa Ana with a funny, high quality video that will be accessible online from anywhere in the world, and this will provide pride and visibility for the City to attract artists, visitors and residents. We will also patronize local restaurants, such as Norms, and businesses such as Samy's Camera, Smart & Final, McLogan, Food Trucks, etc. Portfolio Submission A_Weekend_With_Pablo_Picasso_Interview with_Herbert_Siguenza.mp4 HERBERT_REEL_.mp4 Herbert Siguenza_Video_Portfolio_for "Viva_Santa_Ana.docx Culture_Clash_1.mp4 My Theatrical_Journey.mp4 Letter(s) of support (Up to 2) MASA_Herbert_SigUenza_Letter_of Support.pdf Original artwork design or Schedule of Activities/Curriculum Viv a_Sa nta_An a_poste r.pdf Project Timeline Project_Timeline_Artist_Fillable_Siguenza.pdf Line Item Budget Project_Budget_Artist_Fillable_Siguenza.pdf � 1 March 23, 2026 Dear Santa Ana Arts Grant Panel, I am Founding Director of Media Arts Santa Ana(MASA), and I am writing to give my utmost support and recommendation for Herbert Sig0enza's Viva Santa Ana! proposal to the Santa Ana Investing in the Artist Grant. This project provides a rare opportunity to provide the Santa Ana community with masterclass level training that will result in an original video program that participants and Santa Ana residents will watch with pride for years to come. first met Herbert more than 30 years ago,when I was an arts writer covering his groundbreaking theatre work with his comedy troupe Culture Clash. I have seen Herbert expand his capacity and depth as a writer and performer on stage,television and film,as a director and as a pioneer in documentary theatre. In addition to groundbreaking works such as A Bowl of Beings, Carpa Clash and Culture Clash in AmedCCa, Herbert has gained critical acclaim for his solo plays A Weekend with Pablo Picasso, Stealing Heaven,Manifest Destinitis and El Henry,a Chicanx cyberpunk reimagining of Shakespeare's Henry IV, Part One,which won a San Diego Critics Circle Award. In film, Herbert will be known to Santa Ana audiences as the voice of Tics Oscar and Felipe in the Pixar holiday classic Coco.And as the villain Dr.Victor Valadis in the film Ben 10.Alien Swarm. Herbert Sigiienza is a master of comedy,and working in community is central to his artistic mission.Herbert has worked with students throughout his career and has most recently taught classes at San Diego State University,San Diego City College and New Village Arts in Carlsbad. He is also a regular performer at South Coast Repertory. This project would mark the first time Herbert conducts a workshop in Santa Ana,and Media Arts Santa Ana is honored to be a community partner in this project.We will provide funding support,space,technology and outreach. We will also help connect Herbert with the local arts community and students to ensure success of this program in Santa Ana and to maximize its impact to unite the Santa Ana community via comedic exploration of our community stories and concerns.We have previously presented Herbert in Santa Ana for a community table read of his play-in- development IsaacAsimov_Grand Master Funk at the Santora Building,and for community discussions for the screenings of his films A Weekend with Pablo Picasso and 57 Chevy as part of the OC Film Fiesta. am thanking you in advance for your consideration and urge you to support Herbert Siguenza's proposal for the Viva Santa Ana project.We look forward to the opportunity for Herbert to inspire and transform the Santa Ana community through his work, his generous sharing of knowledge and his mentoring of local artists. Please do not hesitate to contact me at 619-701-0073 or victor@rnasamedia.org if you have any questions. Sincerely, Victor Payan Founding Director Media Arts Santa Ana (MASA) Media Arts Santa Ana • Pp Box 1816 • Santa Ana.CA 92702 • victor@masamedia.org • 619-701-0373 FunnyProject Description "Viva Santa Ana?" is a 25-minute mock TV television show written, produced, filmed, Show. performed, and edited by residents of Santa ' Ana, The program will look and feel like a classic local-interest TV show, featuring Created 4ed by Santa lively hosts, guest interviews, and on-site human-interest segments exploring the Ana Residents. people, culture, and everyday life of the city. Comedic and satirical in tone,the show playfully highlights and skewers the triumphs, contradictions, and challenges 5rA familiar to the community. Local interested - s , participants will learn the ins and outs of producing a real TV show with hilarious results. The participants will research, brainstorm, and write segments skewing JV t local news, people, and civic situations. s Besides being entertaining,this project will promote community engagement and z dialogue about local matters. w� y Work Timelines Creating a mock or real local community TV - - show has to be divided into sections and - — teams. Below are the work timelines to complete the project. September- November: Face-to-face meetings to brainstorm, research, investigate, and begin writing all segments Participants: 10-12 core production team. and ideas. Timeline: September 2026-May 2027. December-March: Identify shooting Launch: May 2027. locations, audition actors, buy costumes and Reach: Worldwide online public viewing, props if needed, and begin shooting video digitally. April-May: Select and edit video. Design sessions will be conducted there, The world graphics and create video transitions. premiere screening and community Premiere the finished project at MASA and reception will be held at MASA. upload to YouTube for worldwide viewership. Project Leader Herbert Siguenza is a veteran stage, film, ' and TV actor, writer, director, educator, and , producer. Herbert is a co-founder of the legendary Chicano comedy troupe Culture 4- Clash. Herbert and Culture Clash have had tremendous success with similar site-specific comedic projects that engage with community members and make them creative members of a production team that El requires teamwork. Herbert will teach participants in writing short-form comedy based on local news and people. Participants are welcome to act in the scenes or audition other residents for the part. Once locations and filming are finished, Production photos oFSDPU Live!(2023). Herbert the process of editing and video graphics Siguenza with SDSU student director and co-producer begins. In 2023, Herbert led and produced Gabriei zendejos. SOPU Live!A mock student TV show completely written, acted, and edited by San Diego State University students, In 2021, Herbert produced a comedic and educational series called The Salve Chronicles about the Salvadoran community in Los Angeles. Community Partner Media Arts Santa Ana (MASA) has agreed to be our local community partner. They are the perfect arts organization that will serve as the home base for the production team. All face-to-face meetings and writing Herbert Siguenza: Santa Ana Investing in the Artist Grant 1 Individual Project Timeline "Input your information directly onto this form and upload onto Submittable.com. DATE ACTION OUTCOME July-Aug. Create outreach campaign to engage Recruit Santa Ana residents from 2026 participants throughout Santa Ana to apply to participate in the Viva Santa Ana project. Sept.-Dec. Face-to-face meetings to brainstorm, research, Select project participants and begin weekly 2026 investigate, and begin writing all segments and classes in Santa Ana with Herbert Siguenza ideas. to teach acting, comedy,story development, video production.Through this activity, we will explore community histories,goals, dream and challenges and discover how to create compelling and funny ways to address them in the format of video and help unite the community around these issues. Jan. 2026- Identify shooting locations, audition actors, Work with project participants in the pre- March buy costumes and props if needed, and begin production, production and post-production 2027 shooting video digitally. phases of the Viva Santa Ana show. Reach out to local organizations, businesses and community members to plan, schedule, produce and film the Viva Santa Ana show. Participants will take turns at writing, acting, directing and producing the segments under the guidance of Herbert Siguenza. April 2027 Review and edit video. Design graphics. music Work with participants and professional and create video transitions. editor to turn footage into finished pieces using programs such as Adobe Premiere, CapCut, GarageBand and Adobe Creative Cloud apps May 2027 Premiere the finished project at MASA and Free community event, screening, YouTube upload to YouTube for worldwide viewership. video launch and food truck at Media Arts Santa Ana's TVGB Digital Maker Space, located at 1666 N Main in Santa Ana. SAMPLE Line Item Budget "Input your information directly onto this form (2 pages)and upload onto Submittable.com(use Google Chrome). PERSONNEL Description of Personnel Grant (artist fees, consultants, administrative Total Compensation Funds fees, etc.) Requested Project Lead $3,500 $6,000 Actors/writers $700 $1,000 Editor/ Designer $700 $1,000 EQUIPMENT, MATERIALS AND SUPPLIES Item Quantit Unit Total Grant materials supplies) Funds (equipment, pp 'lies) y Cast Cast Requested Light, sound rental equipment 1 $300 $ 300 Costumes and properties 1 $200 $250 ADDITIONAL EXPENSES Description Total Cost Grant Funds (permits, fees, facility rental for project) Requested Shooting expenses (food, water, etc) $186 $250 Premiere Expenses $100 $500 1 City of Santa Ana,Community Development Agency 20 Civic Center Plaza, M-25,Santa Ana,CA 92701(714)647-5360 SAMPLE Line Item Budget—Page 2 Enter budget categories and projected expenditures for the proposed program: Expenditures Expenditures Funded By Category Funded By Other Sources Total Project Santa Ana Grant (Including Budget in-kind) Personnel Total $4,000 Equipment Total Supplies Total Materials Total Additional Expense Total In-kind donation from Lead $S00 In-kind donation from MASA $500 $1000 $S,686 TOTAL PROJECT REVENUE LIST ALL OTHER PROJECT RESOURCES "Funding Source" total must equal "Total Project Budget" listed above. FUNDING SOURCE AMOUNT Santa Ana Artist Grant $5,686 In-kind donations $1,000 TOTAL PROGRAM BUDGET $6,686.00 2 City of Santa Ana,Community Development Agency 20 Civic Center Plaza, M-25,Santa Ana,CA 92701(714)647-5360 ACo CERTIFICATE OF LIABILITY INSURANCE DATE(MMJDDIYYYY) 08106/2026 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policy(ies)must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Simply Business CONTACT Simply Business NAME: 53 State Street PHONE FAX 19th Floor AIC No. o Ext: 844 654-7272 A/C No): E-MAIL Boston, MA 02109 ADDRESS: contactus@simplybusiness.com INSURERS)AFFORDING COVERAGE NAIC# INSURER A: RLI 13056 INSURED HerbertSiguenza INSURER I;: 3943 Polack St INSURER C San Diego, California 92110 INSURERD: INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD iNDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER MWDDIYYYr MMIDDmrY LIMITS A X COMMERCIAL GENERAL LIABILITY X Y RL15679005XB 07/3112026 0713112027 EACH OCCURRENCE $1,000,000 AMACLAIMS-MADE OCCUR PREMISESOEa occu ence 50,000 VIED EXP(Any one person) y 5'0}0 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 X PRO. [::] POLICY JECT LOC PRODUCTS-COMPIOPAGG $2,000,000 OTHER: AUTOMOBILE LIABILITY 00 BtNED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) OWNED SCHEDULED BODILY INJURY(Per accident) AUTOS ONLY HIRED NON-OWNED PROPERTY DAMA E AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAR CLAIMS-MADE AGGREGATE DED RETENTION WORKERS COMPENSATION PER (E)TV EMPLOYERS'LIABILITY Y f N STATUTE ER ANYPROPRIETORIPARTNERIEXECUTIVE ❑ E.L.EACH ACCIDENT OFFICERlMEMBEREXCLUDED? NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE If yes,describe under DESCRIPTION OF OPERATIONS below pQ�7�C}VF�_. I E.L.DISEASE-POLICY LIMIT PROFESSIONAL LIABILITY By Tv Tran Ngupett of 11:05am,Aug 07,YD2e 1 EACH CLAIM AGGREGATE DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) RL15679005XB-Refer to Common Policy Declarations-Primary and noncontributory BUSINESS PERSONAL PROPERTY:$5,000 The City of Santa Ana, its City Council,officers,employees, agents,and volunteers are included as an additional insured on the General Liability policy,on a primary and noncontributory basis, per written contract.Waiver of subrogation applies in favor of The City of Santa Ana, its City Council,officers, employees, agents, and volunteers per contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City Of Santa Ana ACCORDANCE WITH THE POLICY PROVISIONS. Attn Executive Director Community Development Agency, 20 Civic Center Plaza, Santa Ana,CA 92701 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION.All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD Policy Number: RL15679005XB1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM Section II—Liability is amended as follows: B. With respect to the insurance afforded to these addi- tional insureds, the following is added to Paragraph D. A. The following is added to Paragraph C. Who Is An Liability And Medical Expenses Limits Of Insured: Insurance: 3. Any person(s) or organization(s) shown in the If coverage provided to the additional insured is Schedule is also an additional insured, but only required by a contract or agreement, the most we will with respect to liability for "bodily injury", "property pay on behalf of the additional insured is the amount damage" or "personal and advertising injury" of insurance: caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting 1. Required by the contract or agreement, or on your behalf in the performance of your ongoing operations or in connection with your premises 2. Available under the applicable Limits Of Insur- owned by or rented to you. ance shown in the Declarations; However: whichever is less. a. The insurance afforded to such additional This endorsement shall not increase the applicable insured only applies to the extent permitted by Limits Of Insurance shown in the Declarations. law; and b. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): Any person(s)or organization(s)whom you are required to add as an additional insured on this policy pursuant to a written contract or written agreement which is: 1. Valid and legally enforceable; 2. Currently in effect or becoming effective during the term of this policy; and 3. Executed prior to an 'occurrence" resulting in "bodily injury" or"property damage" Information required to complete this Schedule, if not shown above, will be shown in the Declarations. BP 04 48 07 13 © Insurance Services Office, Inc., 2012 Page 1 of 1 Policy Number:RL15679005XB1 RLI Insurance Company THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. WAIVER OF TRANSFER OF RIGHTS OF RECOVERY AGAINST OTHERS TO US This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM SCHEDULE Name Of Person Or Organization: Any person(s)or organization(s) to whom the insured has waived its right of recovery in a written contract or written agreement which is: 1. Valid and legally enforceable; 2. Currently in effect or becoming effective during the term of this policy; and 3. Executed prior to an"occurrence" resulting in "bodily injury"or"property damage" Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Paragraph K. Transfer Of Rights Of Recovery Against Others To Us in Section ill — Common Policy Condi- tions is amended by the addition of the following: We waive any right of recovery we may have against the person or organization shown in the Schedule above because of payments we make for injury or damage arising out of your ongoing operations or"your work"done under a contract with that person or organization and included in the "products-completed operations hazard". This waiver applies only to the person or organization shown in the Schedule above. ALL OTHER TERMS AND CONDITIONS OF THIS POLICY REMAIN UNCHANGED. BP 04 97 01 06 © ISO Properties, Inc., 2004 Page 1 of 1 Policy Number: RL15679005XB1 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. PRIMARY AND NONCONTRIBUTORY -- OTHER INSURANCE CONDITION This endorsement modifies insurance provided under the following: BUSINESSOWNERS COVERAGE FORM The following is added to Paragraph H. Other Insurance 2. You have agreed in writing in a contract or of Section III — Common Policy Conditions and super- agreement that this insurance would be primary sedes any provision to the contrary: and would not seek contribution from any other insurance available to the additional insured. Primary And Noncontributory Insurance This insurance is primary to and will not seek con- tribution from any other insurance available to an additional insured under your policy provided that: 1. The additional insured is a Named insured under such other insurance; and BP 14 88 07 13 (D Insurance Services Office, Inc., 2012 Page 1 of 1 CITY OF SANTA ANA �{ . Risk Management a division of Human Resources Managing Risk through Awareness and Action AFFIDAVIT OF EXEMPTION FOR AUTOMOBILE LIABILITY INSURANCE 1, 6A 'S ("Representative"),attest that I am an authorized (Name and'title of vendo epresentative) representative of ("Company"),and (Consultant! ompany ame) possess the authority to legally bind Company. In my capacity as Representative of Company, I represent and confirm the following,as relates to the agreement between Company and City of Santa Ana,agreement number ("Agreement")to provide , Vsr ("Services"): (Services to be provided under agreement/contract) During the course and scope of Company's agreement with the City of Santa Ana, Company employees,consultants,representatives,and agents will not use and/or drive any Company owned/rented/leased/borrowed vehicles to perform Services to, for,or on behalf of City of Santa Ana. If at any time it is found that Company is not adhering to any and/or all of the statements in this document and does not maintain the minimum automobile liability insurance coverage as required in the Agreement, it will be considered a breach of Agreement rendering the Agreement null and void and Company will be fully liable for any and all damages. signature Datc Print Name Aa�7 Titl4 Ae �?4?e ev, Contact taformation.i.e.,Telephone mbar andior Email Address Affidavit of Exemption for Automobile Liability Insurance 11.12.2024 CITY OF SANTA ANA Risk Management a division of Human Resources Managing Risk through Awareness and Action AFFIDAVIT OF EXEMPTION FOR WORKERS' COMPENSATION INSURANCE I, JA21C6DOC %A-&— ("Representative"),attest that I am an authorized (Name and Title of Ve r Representative) representative of 11 W C, ("Company"),and (C nsultan ompany Name) possess the authority to legally bind Company. In my capacity as Representative of Company,I represent and confirm the following,as relates to the agreement between Company and City of Santa Ana,agreement number ("Agreement")to provide_ yo— �o r o— ("Services"): (Services to be provided under agreement'contract) During the course and scope of Company's agreement with the City of Santa Ana,Company will not employ any person in any manner so as to become subject to the workers' compensation laws of California,and agree that if Company should become subject to the workers'compensation provisions of Section 3700 of the Labor Code,Company shall forthwith comply with the provisions and provide proof of workers' compensation coverage immediately, If at any time it is found that Company is not adhering to any and/or all of the statements in this document and does not maintain the minimum professional liability insurance coverage as required in the Agreement,it will be considered a breach of Agreement rendering the Agreement null and void and Company will be fully liable for any and all damages. YJSignature Date ilC y ey-+ L✓ t 1 Print Name A t4ZS r- Titie Contact Information,i.e.,Telephone Number an&or Email A ess WARNING: FAILURE TO SECURE WORKERS'COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO CRIMINAL PENALTIES AND CIVIL FINES UP TO ONE HUNDRED THOUSANT DOLLARS(S 100,000).IN ADDITION TO THE COST OF COMPENSATION,DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE, INTEREST,AND ATTORNEY'S FEES. Affidavit of Exemption for Workers'Compensation Insurance 11.12.2024