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City of Santa Ana <br />City Clerk <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amendments (if any) are no longer in effect.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 City Clerk's Office (M-30). <br />Call 647-6520 if you have any questions. <br />The agreement with <br />N-2023-066 <br />No. was completed on <br />(List all amendments. Use space below if needed.) <br />bagreemenMformsWorm - agreement termination form—goldenrod.doc <br />COTC Office Use ON <br />C-Z00 <br />City ()f Santri, Ana <br />onty Clerk's 0ifiCS <br />ly ICI and final payment has been made. <br />Department: L-001) ✓ <br />Phone/Ext.: , <br />Signature: <br />Ar <br />Date: ,�r <br />