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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amendments (if any) are no longer in effect.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. ''} i. was completed on <br />(List all amendments. Use space Below if needed.) <br />hagreementsWormstform - agreement termination form—goldenrod.doc <br />COTG Office Use aniY <br />CZo2Z <br />city of rants AW <br />JAN I I IS <br />city Clerk's Office <br />and final payment has been made. <br />Department: � t j`a, <br />Phone/Fxt.: 5 3 V <br />Signature: <br />Date:' <br />