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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amendments (if any) are no longer in effect.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 />d-uo\, mmi <br />N 2023-202 was completed on '' <br />No. <br />(List all amendments. Use space below if needed.) <br />Department: <br />Phone/Ext.: <br />Signature: <br />Date: <br />i:lag reementsWormsWorm - agreement termination form ,goldenrod, doc <br />CQTC Office Use ©nl <br />C 2-0 2:�-,> <br />CltY Of Santa Ana <br />JAN 11 2w <br />'Ity Clark's Office <br />and final payment has been made. <br />