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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amendments (if any) are no longer in effect.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 />No. a- X11—Moo was completed on <br />(List all amendments. Use space below if needed.) n <br />l ` <br />Department: <br />Phone/Ext.: <br />Signature: <br />Date: <br />COTC Office Use Only <br />7'" J(tL 19 p; 3: n 9 <br />CITY op <br />CLERK 0, OUr� AN <br />and final payment has been made. <br />Revised: 10-18-16 <br />