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City of Santa Ana <br />Clerk of the Council <br />AGREEMENT TERMINATION FORM <br />Please complete this farm in its entirety when the aftached 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amendments (if any) are no longer in effect.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 <br />A-2021-107-02 .. <br />No. <br />(List all amendments. <br />was completed on I Lf`` <br />Use space below if needed) <br />lagreementsiformsVorm - agreement termination form—goldenrod.doc <br />Department: <br />COTC Office Use Only <br />C 2-0 2,3 <br />city of 'Santa An <br />JAN 11 2024 <br />city Clergy's OfficE, <br />and final payment has been made. <br />Phone/Ext.: <br />Signature: <br />Date: <br />