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City of Santa Ana <br />t 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amendments (if any) are no longer in effect.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 I riCym( Zi�rowSki <br />COTC Office Use Only <br />f�j T - q; iRjkfC1H <br />3 <br />No. N-2021-126 was completed on W and final payment has been made. <br />(List all amendments. Use space below if needed.) Department: ftct hAx e. <br />Phone/Ext.: rJ3 p,�j to (53l <br />Signature: l r�iy✓w4�� <br />Date: <br />ilagreementsWormsWorm - agreement termination form_goldenrod.doc <br />