Attachment_10_-_Individual___Sole_Proprietor.pdf

PDF 35 KB Posted

Attached to
RFP-24-004 NATIVE AMERICAN & INDIGENOUS ARTISTS CONSULTANT SERVICES
Solicitation number
0000034798
Issued by
Sacramento County, Sacramento City, West Sacramento City, California

About this file

Written by GovTribe AI ·

This document is an Attachment 10 form for an Individual or Sole Proprietorship Exempt from Workers' Compensation Insurance Statement, associated with RFP-24-004 from the State of California's Department of Rehabilitation. The form is a legal certification document for an individual or sole proprietor who does not currently employ any workers, thus exempting them from California's Workers' Compensation Laws.

The form requires the vendor to certify under penalty of perjury that they do not employ any persons in a manner that would make them subject to Workers' Compensation Laws. Additionally, the vendor commits to notifying the Department of Rehabilitation within 90 days if their business status changes and they become subject to these laws. The document provides spaces for the vendor's printed name, signature, and date, and is part of the solicitation process for RFP-24-004.

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ATTACHMENT ____: Individual or Sole Proprietorship Exempt from Workers’ Compensation Insurance Statement

______ of ______

I certify under penalty of perjury under the laws of the State of California that I do not employ any person in any manner as to become subject to the Workers’ Compensation Laws of California.

I further certify that the Department of Rehabilitation will be notified within ninety (90) days of any changes which results in the business becoming subject to the Workers’ Compensation laws of the State of California.

RFP No.: _____________________

Print Name Date

Signature

Compensation Insurance Statement: 10
RFP No: RFP-24-004
Print Name:
Date:
of:
undefined:

File details come from the government source that posted it. Updated .