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City of Santa Ana _ <br />05--A <br />Clerk of the Council COTC Office Use Only <br />_ _ <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agreement and <br />amendments (if any) are no longer in effect. i Fri I I PM 4 Q� <br />Note: If your agreement is grant related, please ensure that all grant retention requirements CI j, I, <br />have been satisfied prior to signing the termination form. OF <br />S ;� Iri QI��i CL n i OF COUNCIL I Is the agreement(s) a permanent record? Yes No <br />Return form to the Clerk of the Council Office (M-30). <br />Call 647-1520 if you have any questions. <br />/C (livC <br />The aareement wi+n <br />A-2016-018-02 <br />No. was completed on and final payment has been made. <br />(List all amendments. Use space below if needed.) ✓� (�i,� <br />Department: <br />o Phone/Ext.: 13 <br />Signature: <br />Date: <br />Revised: 10-18-16 <br />