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City of Santa Ana <br />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amendments (if any) are no longer in effect.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 />------ C <br />Office Use Only <br />. <br />_y't/ M�)T <br />?J <br />CITY n-A1,rf, ^urm <br />No. N-2017-036 was completed on _ and final payment has been made. <br />(List all amendments. Use space below if needed.) <br />Department: IP <br />Phone/Ext.: <br />Signature: 21 , � i A)! Irwn <br />k <br />Date: l® `t�S I rl <br />Revised: 10.1&16 <br />