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City of Santa Ana <br />W City Clerk <br />AGREEMENT TERMINATION FORM <br />COTC Office Use Only <br />R A CITY CLERK <br />A U 0 2 '21OR: <br />Please complete this form in its entirety when the attached agreement and rill <br />amendments (if any) are no longer in effect. <br />Note: If your agreement is grant related, please ensure that all grant retention requirements <br />have been satisfied prior to signing the termination form. <br />Is the agreement(s) a permanent record? Yes No <br />Return form to the City Clerk's Office (M-30). <br />Call 647-6520 if you have any questions. <br />C2012 <br />The agreement with <br />No. was completed on fl'�(ZA' 72- and final payment has been made. <br />(fist all -amendments. Use spacebelow if needed.) <br />Department:r <br />Phone/Ex <br />Signature <br />Date: <br />i1agreementsWormsVorm - agreement termination form goldenrod.doc <br />