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- OCity of Santa Ana <br />Z- Clerk of the Council <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amendments (if any) are no longer in effect.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 Clerk of the Council Office (M-30). <br />Call 647-1520 if you have any questions. <br />The agreement with <br />`✓ <br />COTC Office Use Only <br />Y 0IF Wti+tT.A <br />No. N-2016-160 was completed on and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />Department: <br />Phone/Ext.: <br />Signature: S QkL 'l G, I=PA/iA /� <br />—Date: <br />�a�iAL <br />Revised: 10-18-16 <br />