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City of Santa Ana <br />Clerk of the Council coTcOffice Use Only <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agreement and all <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amendments (if any) are no longer in effect.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 d <br />Return form to the Clerk of the Council Office (M-30). <br />Call 647-1520 if you have any questions. <br />The agreement with Vow, ICU Cmps <br />N-2019-005 <br />No. was completed on 12161110101 and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />Department: Q CEA <br />Phone/Ext.: <br />Signature: <br />o— <br />Date: In I %F11 20M <br />Revised: 10-18-16 <br />