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City of Santa Ana <br />m; Clerk of the Council <br />AGREEMENT TERMINATION FORM <br />Please complete this form when the attached agreement and all <br />amendments (if any) are no longer in effect. <br />Return form to the Clerk of the Council Office (M -30). <br />Call 647 -6520 if you have any questions. <br />The agreement with Correctional Managed Care Medical Corporation <br />C2p� <br />COTC Office Use Only <br />`" <br />'ITS of <br />No. A- 2009 -146 was completed on 8 -31 -2013 and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />A- 2011 -228, A- 2012 -179 Department: Police Department <br />Phone /Ext.: (714) 245 -8004 <br />Signature: � <br />Date: �2J V5 <br />Revised 08 -23 -10 <br />