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City of Santa `-a <br />=_= i Clerk of the Cou..Jl <br />AGREEMENT TERMINATION FORM <br />Please complete this form in its entirety when the attached agreement( cF90 <br />amendments (if any) are no longer in effect. <br />Note: If your agreement is grant related, please ensure that all grant retention requirementsC I T Y OF <br />have been satisfied prior to signing the termination form. CLERK <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. &Z-Ol y- a(z- was completed on <br />(List all amendments. Use space below N needed.) <br />COTC Office Use Only <br />6 PM 3� ? 7 <br />NTA ANA <br />COUNCIL <br />)$ and final payment has been made. <br />Department: PP-CSA <br />Phone/Ext.: L/3I!q <br />Signature:, <br />Date: <br />Revised: 10-18-16 <br />