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0City of Santa A "i � corc omce use Only <br />Clerk of the Counted <br />='- �� <br />r P�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amendments (if any) are no longer in effect.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�r°aLt ems. <br />have been satisfied prior to signing the termination form. `" 5` "M° <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 />N-2022-228 <br />No. was completed on $ 2gL-7 and final payment has been made. <br />(List all amendments. Use space below if needed.) t� <br />Department: rC <br />Phone/Ext.:o�Zp <br />Signature: <br />r 11 <br />Date: <br />