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City of Santa Ana <br /> Clerk of the Council COTC Office Use Only <br /> AGREEMENT TERMINATION FORM <br /> rq <br /> I f) i,Please complete this form in its entirety when the attached'agreement ana all rL.: n <br /> amendments (if any) are no longer in effect. <br /> Note: If your agreement is grant related, please ensure that all grant retention ruirements 1 • Z. ,! - <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 3169702- 1/45 _fivIa541, 11 ) ,t-nd <br /> No. A- 9-61(1- / /I was completed on 01'1 LS and find payment has been made. <br /> (List all amendments. Use space below if needed.) ee (/ -4720,410 <br /> Department: f/1$ñ bI6 <br /> Phone/Ext.: /797 `,2/11*.)11 <br /> Signature: <br /> Date: <br /> Revised: 10-18-16 <br />