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City of Santa " na COTC Office Use Only <br />t Clerk of the Council 1 <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amendments (if any) are no longer in effect. C`EFk yr THE Cp g N g j <br />Note: If your agreement is grant related, please ensure that all grant retention requirements EE13128'21 PM4':32 <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 f l <br />A-2021-068-04 � <br />No. was completed on 1 tL lit - and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />Department: CUPS <br />Phone/Ext.: <br />Signature: <br />Date: <br />i1agreementr;Vorms\form - agreement termination form_goldenrod.doc <br />