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City of Santa Ana <br />Clerk of the Council <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amendments (if any) are no longer in effect.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. Is the agreement(s) a permanent record? Yes _ No ./ <br />Q. <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 <br />No. Q—aoG-d(g'�? was completed on 12131 i 201() and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />Department: �� C <br />Phone/Ext.: <br />Signature: ( Jl "C a <br />Date: r-M ICi l lC2 \ \ <br />Revised: 10-18-16 <br />