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City of Santa 0 na <br />Clerk of the Cou.,cil <br />AGREEMENT TERMINATION FORM 5A 1 Ole <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amendments (if any) are no longer in effect.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 farm. / <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 />L <br />A-2020-067-03 <br />No. was completed on <br />(List all amendments. Use space below if needed.) <br />i7agreementsUormslform- agreement terminafion form _goldenrod.doc <br />COTC Office Use Only <br />LIF THE CC€ NUL <br />12 '23 P142:25 <br />"/ � — � and final payment has been made. <br />Department: l�j ✓y/ 7 <br />Phone/Ext.: I �� <br />Signature: <br />Date: <br />