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City of Santa Ana <br />Clerk of the Council <br />AGREEMENT TERMINATION FORM <br />Please complete this form inits entirety when the attached agreement ono61�7 <br />amendments (if any) are oolonger ineffect. 1�M~,,,, <br />Note: If your agreement is grant related, please ensure that all grant retenfion requirements <br />have been safisfied p(ior to signing the termination form. <br />|sthe agro*monKy)upermanent record? Yes N0 <br />Return form to the Clerk of the Council Office (M-30). <br />Call 647-l520ifyou have any questions. <br />The agreement with <br />r/ <br />N~2016~176 � <br />No� was completed on / and final payment has been made. <br />(List alf amendments. Use space below ff needed.) <br />Department: <br />Phone/Ext.: <br />Signature: <br />Date: It n <br />Revised* 10-18-16 <br />