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City of Santa Ana <br />' ~ I Clerk of the Council core office use only <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agreement AT Err 12 M 9: Lj9 <br />amendments (if any) are no longer in effect. _ <br />Note: If your agreement is grant related, please ensure that all grant retention requirements Ci T Y OF SA NTA ANA <br />have been satisfied prior to signing the termination form. ti Y` Cr COUNCIL <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'cL <br />No. /7 �� ® 3 was completed on/ and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />Department: <br />r X Phone/Ext.: <br />— � ( Signature: n-8 R /EL <br />Date: <br />R:vi;ah: 12-13-16 <br />