Rev: 0 | Revision Date: 01/30/2024 | Print Date: 0/00/0000 I.D. Number: BOAAAF
relating in any way to the City of Fort Lauderdale's reliance of the authority granted to my Authorized Agent pursuant to this Form.
BY SIGNING THIS RELEASE AND HOLD HARMLESS AGREEMENT, I ATTEST, AFFIRM, AND REPRESENT THAT I AM THE TITLE OWNER/AUTHORIZED PERSON FOR THE PROPERTY AND THAT ALL OF THE FOLLOWING STATEMENTS ARE TRUE AND CORRECT: I am at least eighteen (18) years of age and of sound and competent state of mind at the time executed this Agent Authorization Form; I executed this Agent Authorization Form as an expression of my own free act and deed; There are no oral representations or statements, apart from this Agent Authorization Form and intend to be bound by its terms; and I was not induced by the City, its employees and/or agents, or anyone, to execute this
Agent Authorization Form. *Please provide proof of ownership. If the property is owned by an Corporation, please submit Sunbiz Verification with this form.
Morgan Elliott Witness Signature
Morgan Elliott Print Name 1/14/2026 Date
Diana Urbina Signature - Owner/Authorized Individual
Diana Urbina Print Name - Owner/ Authorized Individual
Sr. Property Manager Print Title - Authorized Individual
STATE OF Florida COUNTY OF Bowland The foregoing instrument was acknowledged before me by means of physical presence or online notarization, this day of Jan. 2026 by Diana Urbina, an individual who is personally known to me or has produced as identification
The foregoing instrument was acknowledged before me by means of physical presence or online notarization, this 13 day of Jan, 2026 by Diana Urbinia, an individual who is personally known to me or has produced as identification
ANGELA RYAN MY COMMISSION # HH 686261
[NOTARY'S]
(Signature of Notary Public- State of Florida) 10-9-2029 My Commission Expires:
EXPIRES: October 9, 2029 (Signature of Notary Public- State of Florida) 10-9-2029 My Commission Expires:
Miyela Kymn
Print./Type. or Stamp Commissioned Name of Notary Public