I acknowledge that any false statement or other misrepresentation made on this form may subject me to civil and criminal penalties. I agree to indemnify and hold harmless SurePayroll, its affiliates and subsidiaries and each of their respective officers, directors, managers, members, employees and agents from any and all liability arising out of any fraudulent statements.
By submitting this form, I declare under penalties of perjury under the laws of the State of California that the foregoing information is true and correct.