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City of Santa Ana <br />-- Clerk of the Cou..,:il <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amendments (if any) are no longer in effect.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 pletonr <br />8uf leii <br />COTC Office Use On <br />O1= THE COUNCIL <br />3 28123 PM4:32 <br />A-2021-068-09 <br />No. was completed on and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />Department: (,Q(+ <br />Phone/Ext.: (15 (J l <br />Signature: <br />Date: <br />idigreemenlsWormslform- agreement termination form_goldenrod.doc <br />