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City of Santa Ana {` <br />Clerk of the Council VI rt1 ° oxc Office Use <br />AGREEMENT TERMINATION FORM <br />z r ei 3E <br />Please complete this form in its entirety when the attached agreemeC4d Ia <br />amendments (if any) are no longer in effect. <br />r d T Y ^yea 3. rtes <br />J f A <br />Note: If your agreement is grant related, please ensure that all grant retention requirementsn r r <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 />No. N-2017-020 was completed on ,21J201 17 and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />Department: Fw-sof <br />Phone/Ext.: SSS /1 <br />Signature: <br />Date: <br />Revised: 10-18-16 <br />