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City of Santa Ana COTc Office Use Only <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amendments (if any) are no longer in effect.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. / <br />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 />The agreement with t*AI t MaG,Z <br />N-2021-004 <br />No. was completed on j 131 2OU and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />ilagreememsVormsWorm - agreement termination form_goldenrod.doc <br />Department: COA A 5 I A( iVf-U <br />Phone/Ext.: 53$5 Of3�5 <br />Signature: 1 A�%n� <br />U <br />Date: (43017DV <br />