HomeMy WebLinkAbout4-16-2020 Commission packetIf you will need disability related accommodations to participate in this program or event, please contact
LaTasha DeLoach at latasha-deloach@iowa-city.org or 319-356-5225. Early requests are strongly encouraged to
allow sufficient time to meet your access needs.
Senior Center Commission Agenda
Thursday, April 16, 2020
Electronic Meeting - 4 PM
ZOOM MEETING PLATFORM
1. Introductions/Welcome—S. Finlayson
2. Minutes (February 20, 2020)
3. Public Discussion for items not on the agenda
4. Commission Assignments— S. Finlayson
Board of Supervisors
City Council
Electronic Meeting
(Pursuant to Iowa Code section 21.8)
An electronic meeting is being held because a meeting in person is
impossible or impractical due to concerns for the health and safety of
Commission members, staff and the public presented by COVID-19.
You can participate in the meeting and can comment on an agenda
item by joining the Zoom meeting via the internet by going to
https://zoom.us/j/270659984. If you are asked for a meeting ID, enter Meeting
ID: 270 659 984 to enter a 'Waiting Room' for the meeting.
If you have no computer or smartphone, or a computer without a
microphone, you can call in by phone by dialing (312) 626-6799 and
entering the meeting ID when prompted. Providing comment in person is
not an option.
If you will need disability related accommodations to participate in this program or event, please contact
LaTasha DeLoach at latasha-deloach@iowa-city.org or 319-356-5225. Early requests are strongly encouraged to
allow sufficient time to meet your access needs.
5. Operational Overview—Staff
❖ Covid-19 Update
❖ RFP Update
❖ Senior Center Policies
❖ Room Rental Document
- Deposit amount change
- Collection of funds rental rates
6. Commission Discussion— S. Finlayson
❖ Current and Potential Community Partners
❖ North Liberty Transportation – A. McConville
❖ Future Agenda Items
7. Adjourn
**Next meeting is Thursday, May 21 at 4 PM **
Meeting Packet Contents:
1. Agenda: Thursday, April 16, 2020
2. Minutes: Senior Center Commission, Thursday, February 20, 2020
3. Policies: Community Use of Center Space; Displays, Bulletin Boards, Materials
Distribution; Pantry Exchange
4. Room Rental Document
5. North Liberty Transit Report
Preliminary Minutes
February 20, 2020
1
MINUTES
SENIOR CENTER COMMISSION
February 20, 2020
ROOM 205, IOWA CITY/JOHNSON COUNTY SENIOR CENTER
Members Present: Lorraine Dorfman, Scott Finlayson, Zach Goldsmith, Angela
McConville, George Nelson, Linda Vogel, Paula Vaughan
Members Absent: None
Staff Present: LaTasha DeLoach, Kristin Kromray, Ashley Monroe
Others Present: Allie O’Connell
CALL TO ORDER:
The meeting was called to order by Dorfman at 4:00 PM.
RECOMMENDATIONS TO COUNCIL:
None.
APPROVAL OF MINUTES FROM THE January 16, 2020 MEETING:
Motion: To accept the minutes from the January 16, 2020. Motion carried on
a vote of 7/0. Goldsmith/Vogel
PUBLIC DISCUSSION:
Assistant City Manager, Ashley Monroe is on the Census 2020 Complete Count
Committee, whose goal is to spread awareness for the upcoming census. She
explained the importance of the census and how federal money is allocated
based on the information gathered. The census begins April 1st. Citizens will be
able to do the census online and then reminders will be sent before a paper copy
is sent.
COMMISSION ASSIGNMENTS:
Vogel will attend an upcoming City council meeting. Nelson noted there is a City
Council listening post on 2/27/2020 at the Senior Center and it might be nice to
have commissioners attend.
OPERATIONAL OVERVIEW:
Preliminary Minutes
February 20, 2020
2
DeLoach reported the request for proposal for the building assessment will be
coming before City Council in the next month.
The Senior Center survey is off to a good start. The cut of date is March 1st. The
Senior Center mailed 5000 surveys as well as having the opportunity to do the
survey digitally as well. Once the results are tabulated a public meeting may be
held to discuss results.
DeLoach has an idea about a senior center in a box. She is form ulating this idea
and will have additional information later.
COMMISSION DISCUSSION:
The commission discussed the demographics in the packet and whether they
would like to see them on a more frequent basis.
Motion: To receive demographic information on an annual basis. Motion
carried on a vote of 7/0. Goldsmith/Dorfman
Emily Edrington submitted a pantry report. Amazon gifted the Senior Center all
items on our wish list in December. Pantry is available to anyone in the
community and has been in place for over a year now. Approximately 100
pounds of food are received every week. Nelson would like to see fresh fruits and
vegetables through table to table be utilized. DeLoach noted that she had been in
contact with Table to Table. She stated we need to be a little careful with
perishable items due to the limitations we have. But she agrees it will be nice to
have some fresh options there as well. The Senior Center did partner with
Horizons last summer and received vegetables and fruit that they could not use.
Vaughan mentioned that the community gardens might be a good partnership.
Intern, Allie O’Connell, is working on an op ed for the newspaper regarding the
first year of the pantry.
Finlayson will bring a survey to the next commission meeting. He is hoping to see
what other community organizations commissions are involved with in the hope
of networking to spread information about the Senior Center. He is working on
making name tags for the commissioners.
McConville, reported the partnership with the Senior Center and North Liberty is
going well with people attending the classes in North Liberty and routinely noting
the information in the program guide.
Vogel noted that Artisan’s gallery may be interested a in a partnership with the
Senior Center.
Preliminary Minutes
February 20, 2020
3
Future agenda items:
- Discuss ways the Commission might get more involved. Add vision discussion to
all commission agendas
- Discuss 3 years of demographic data from fiscal years 2017-2019
Motion: To Adjourn. Motion carried on a vote of 7/0. Goldsmith/Vaughan
Preliminary Minutes
February 20, 2020
4
Senior Center Commission Attendance Record
Name Term Expires 3/21/19 4/25/19 5/16/19 6/20/19 7/18/19 8/14/19 9/19/19 10/17/19 11/21/19 12/19/19 1/16/20 2/20/20
Kenn Bowen 12/31/19 NM X
X NM X X NM NM NM X -- --
Cheryll Clamon 12/31/19 NM X X NM X X -- -- -- -- -- --
Lorraine
Dorfman
12/31/21 NM O/E X NM O/E X NM NM NM X X X
Robert (Scott)
Finlayson
12/31/20 NM X O/E NM O/E X NM NM NM X X X
Zach Goldsmith 12/31/21 NM X X NM X X NM NM NM X X X
Angela
McConville
12/31/21 -- X X NM X X NM NM NM X X X
George Nelson 12/31/22 -- -- -- -- -- -- -- -- -- -- X X
Paula Vaughan 12/31/22 -- -- -- -- -- -- -- -- -- -- O/E X
Linda Vogel 12/31/20 -- -- -- -- -- -- -- -- -- -- X X
Hiram (Rick)
Webber
12/31/19 NM X X NM X O/E NM NM NM O/E -- --
Key: X = Present
O = Absent
O/E = Absent/Excused
NM = No meeting
-- = Not a member
Title: Community Use of Center Space
Date of Current Version: April 2020
Replaces Version: April 2012
Background
The Center supports the needs of the community by providing opportunities for community members
and organizations to use the facility to disseminate information, offer programs, hold meetings, or host
events. Rentals of the facility provide the opportunity to generate revenue that supports operational
expenses.
Community Use of Center Space
General Guidelines
1. When planning programs and activities, Center space needs have priority over all other requests.
2. Requests to schedule space can be made by:
a. Individuals (for their personal, not business, use)
b. Community groups
c. 501c3 Non-profit organizations
d. For-profit organizations and businesses
e. Candidates for Political Office and Political Parties
f. Government entities
3. The location of scheduled space may be changed due to unforeseen circumstances involving the
operation of the facility.
4. The specific areas of the facility available for rent (i.e., for a fee) or use (i.e., for no fee) are
determined by the coordinator or designee.
5. Space is reserved on a first come, first served basis.
6. Janitorial services are not provided. Room set-up and return to its original configuration is the
responsibility of the individual or group.
7. Publicity for all events is the responsibility of the sponsoring individual or group. It must not be
intrusive to participants or disruptive to Center programs and operations.
8. The Center neither approves nor disapproves content, ideas or subject matter presented in the
space and does not accept responsibility for ensuring accuracy or that all points of view are
represented.
9. Coordinator or designee approval is required to serve or prepare food and non-alcoholic
beverages in permitted areas of The Center.
10. All activities held at the Senior Center must comply with Senior Center policies and City of Iowa
City resolutions and ordinances. Users and renters of space must follow all applicable City of Iowa
City codes and The Center code of conduct. If found in violation of any city code, the person or
group will be asked to stop the activity or vacate the premises. If the person or group refuses or
are repeat offenders, police will be summoned.
11. Propping open an exterior door of the facility for any reason is prohibited.
12. Scheduling repeating uses or rentals is permitted in four-month intervals: January-April; May-
August; and September-December. Rooms are not intended for multiple day exhibitions or
displays unless approved by the coordinator or designee.
13. Rental agreements for one-time events can be made up to 12 months in advance, except for
rental requests for the Assembly Room which may be made up to 24 months in advance.
Space Use and Rental During Business Hours
1. The operations assistant or designee coordinates all community space usage.
2. During business hours individuals, 501c3 non-profit organizations, community groups, and
government entities may use the space free of charge.
3. For-profit businesses, political candidates and political parties must rent space during business
hours.
4. The individual or group shall identify a contact person and provide contact information at the time
of reserving space.
5. A table to disseminate information may be reserved by individuals, 501c3 non-profit
organizations, community groups, and government entities at no cost if space is available and
such use does not interfere with Center programs or operations. The following conditions
apply:
a. Tables or displays must be confined to the designated space.
b. Tables or displays must not be intrusive to Center visitors. Table staffers shall not approach or
overtly solicit the involvement of participants or visitors.
Space Rental During Non-Business Hours
1. The operations assistant facilitates all rentals of the facility. Coordinator or designee approval is
required.
2. A Room Use and Rental Application/Letter of Agreement must be submitted to the operations
assistant no later than five (5) business days prior to the requested time of use. Rental fees and
deposit money are required to officially reserve the rental space.
3. A City Council approved schedule of rental fees and security deposits is applied. Each are reviewed
periodically by Center staff and the Senior Center Commission. Recommended changes are
submitted to the City Council for approval. If programming aligns with the Senior Centers mission
and is open to Senior Center members, rental fees may be waived at the discretion of the Senior
Center coordinator.
4. All deposits shall be returned, in part or full, depending upon the condition of the area and
equipment utilized, within 30 days following the scheduled use of space.
5. Additional charges may be required for damage to the facility or equipment, or rental of space
extending beyond the initially agreed upon time limit.
6. Renters must agree to all items on the Room Use and Rental Application/Letter of Agreement.
7. Individuals and community groups:
a. Rental fees are only for weekend and evening use of the facility.
b. Standard rental fees and security deposits are assessed.
8. 501c3 Non-profit organizations:
a. Rental fees are paid only for weekend and evening use of the facility.
b. Receive a 50% discount on rental fees.
c. Security deposits are paid at the standard rate.
9. For-profit organizations and businesses:
a. Rental fees are paid each time the facility is used.
b. Standard rental fees and security deposits are assessed.
10. Political candidates and political parties:
a. Rental fees are paid each time the facility is used.
b. Standard rental fees and security deposits are assessed.
c. The Center shall not sponsor any activities that have the purpose or effect of endorsing a
political party, candidate, or point-of-view.
d. When requested by recognized political parties for space to hold a caucus, meeting space is
provided without charge. For all other room use purposes, political candidates and political
parties pay rental fees each time the facility is used.
e. Candidates, political campaign staff and volunteers, and political party staff shall not disturb
visitors or participants in any other program or service offered at The Center. Interaction with
candidates, political campaign staff and volunteers, and political party staff must be initiated
by the visitor or participants.
11. Government Entities:
a. Rental fees are paid only for weekend and evening use of the facility.
b. Standard rental fees and security deposits are assessed.
Sales and Participation Fees
1. No fundraising, charging of admission, and/or sale of items or services are allowed without Senior
Center coordinator approval. Additional rental fees may apply.
2. Charges solely to recoup program and material costs are acceptable on a case by case basis as
authorized in advance by the coordinator or designee.
3. 501c3 non-profit organizations collaborating with The Center to offer evening and weekend
programs of interest to the 50+ population may assess participation fees for specific events or
programs.
4. Requests to use the building for fund-raising efforts sponsored by in-house agencies (e.g., Senior
Nutrition Program, VNA, TRAIL), other departments within the City of Iowa City, or Johnson
County will be considered on a case by case basis by the coordinator or designee.
Administration
The Center coordinator or designee administers space and use policies. Decisions to deviate from the
policy will be made by the coordinator or designee on a case by case basis.
Approved by the Senior Center Commission on:
1
Title: Displays, Bulletin Boards, Resource Materials Distribution
Date of Current Version: February 2020
Replaces Version:
Background
The Senior Center has various bulletin boards, display spaces, and areas for material distribution that are
used to promote Senior Center programs and services, and to share community information and
resource materials with participants and visitors.
Senior Center Bulletin Boards and Digital Signs
1. The purpose of these spaces is to provide information regarding Senior Center sponsored
activities.
2. Requests to post items on these spaces by partner organizations can be made to the Coordinator
or designee.
3. Materials that have not been approved will be removed.
Non-Profit Bulletin Board
1. Non-profit organizations can display information/promotional flyers in designated areas.
2. Preference will be given to organizations dealing with aging or providing services relevant to the
50+ population.
3. Flyers are given to staff to post.
4. Flyers larger than 8.5x11 inches in size will be displayed only if space is available.
Public Bulletin Board
1. Community information, volunteer or job opportunities, and IRB approved research flyers may be
displayed on the public bulletin board.
2. Staff may review flyers at regular intervals and remove excess or outdated materials.
3. All flyers must meet existing State and Federal laws on obscenity, libel, defamation of character or
invasion of privacy.
4. The Senior Center does not accept responsibility for ensuring that information is accurate or that
all points of view are represented.
Resource Materials Distribution
1. Businesses and organizations that provide services relevant to the 50+ population can supply up to
ten (10) copies of informational materials to be placed in designated areas of the facility.
2. Materials found in non-designated areas of the facility will be discarded.
3. Materials are periodically reviewed by staff; excess or outdated materials will be discarded.
4. Approaching participants or visitors to distribute information is prohibited.
Displays
1. Outside organizations may request display space at the Senior Center.
2
2. The coordinator or designee reserves the right to refuse display space to exhibits which, in their
opinion, does not further the Senior Center’s mission.
3. The Senior Center assumes no responsibility for theft, loss, damage or destruction of items left for
display.
4. All displays must meet existing State and Federal laws on obscenity, libel, defamation of character
or invasion of privacy.
5. The Senior Center does not accept responsibility for ensuring that information is accurate or that
all points of view are represented. Granting of permission to display materials does not imply
Senior Center endorsement of content.
6. Priority is given for displays that are pertinent to the 50+ population and/or groups and individuals
within Johnson County.
7. Name and contact information for the group or individual preparing the display must be part of
the display.
8. Displays will be confined to the space approved by the coordinator or designee.
9. Senior Center staff may remove displays remaining past the scheduled display end date.
Administration
The Center coordinator or designee is responsible for oversight of this policy.
Approved by the Senior Center Commission on:
1
Title: Pantry Exchange
Date of Current Version: February 2020
Replaces Version:
Background
The Iowa City Senior Center Food Pantry was established to help all members of the community facing
food insecurity.
Pantry Guidelines
1. All members of the community are welcome to donate or take items from the pantry. There are
no eligibility requirements for utilizing the pantry.
2. Donations of non-perishable food items, personal hygiene supplies, and pet food are accepted.
3. Shelf-stable food items beyond their expiration date may be accepted at the discretion of staff
or pantry volunteers.
4. Staff and pantry volunteers may discard foods that are exceptionally expired, cans that are badly
dented or rusted, perishable foods, opened or home-made foods.
Administration
The pantry is administered by the Community Outreach Specialist or designee.
Approved by the Senior Center Commission on:
Senior Center Rental Information and Application
The Iowa City Senior Center is located at 28 S Linn St in downtown Iowa City. Built in 1904 and expanded
in 1932, the Senior Center was originally the Iowa City Post Office. The City of Iowa City purchased the
building in 1979 and renovated it to be the Senior Center, which opened in 1981. The lobby and grand
staircase were placed on the National Register of Historic Places in 1979 and on the local Historic
Register in 2019.
The Senior Center has a number of meeting and event spaces available for rent. The Senior Center is
attached via a skywalk to the Tower Place Parking Ramp for convenient parking.
Assembly Room
The Assembly Room has a maximum capacity of 225 people. Amenities include 4 (36”) round tables, 6
(2.5’x6’) tables rectangular tables, and 80 chairs. Audio visual equipment includes: mounted digital video
projector and large permanent screen, HDMI and VGA inputs for laptops, auxiliary audio port, wireless
lavalier microphones, a wireless hand-held microphone, and Blu-ray player. Additional tables and chairs
are available on request.
Room 202
Room 202 has a maximum capacity of 50 people. Amenities include 8 (3’x3’) square tables, 10 (2’x5’)
rectangular tables, and 50 chairs. Audio visual equipment includes: mounted digital video projector and
large permanent screen, HDMI and VGA inputs for laptops, auxiliary audio port, a wireless lavalier
microphone, a wireless hand-held microphone, and Blu-ray player.
Room 208
Room 208 has a maximum capacity of 25 people. Amenities include 5 (3’x3’) square tables, 8 (2’x5’)
rectangular tables, and 25 chairs. Audio visual equipment includes: mounted digital video projector and
large permanent screen, HDMI and VGA inputs for laptops, auxiliary audio port, a wireless lavalier
microphone, a wireless hand-held microphone, and Blu-ray player.
Rooms 205 and 209
Rooms 205 and 209 each have a maximum capacity of 15 people. Amenities include 6 (2’x5’) rectangular
tables and 15 chairs.
Rooms 103 and G13
Rooms 103 and G13 have hard wood floors ideal for fitness or dance practice. G13 has two mirrored
walls; 103 does not have mirrors. There are no food or drinks allowed in these rooms.
Rental Fees
Room Rental Cost Deposit
Rooms 202, 205,
208, and 209
$40/hour $125
Rooms G13 and
103
$60/hour
$125
Assembly Room Monday – Thursday: 8:00 a.m. to 12:00 a.m.
Friday: 8:00 a.m. to 5:00 p.m.
$60/hour; rentals >5 hours will be charged $375
Friday: 5:00 p.m. to 12:00 a.m.
Saturday and Sunday 8:00 a.m. to 12:00 a.m.
$120/hour; rentals >5 hours will be charged $750
$300; if serving
alcohol $500
Individuals and non-profit organizations (who are not requesting to sell items) are not charged a room
rental fee during business hours (8:00 a.m. to 5:00 p.m. Monday-Friday).
Non-profit organizations receive a 50% discount for evening and weekend rentals.
Rental Terms and Conditions
1. Rental Time: Renters will be responsible for paying the rental fee listed from the “start time” to
the “end time” on the Rental Application. Set-up and clean-up time should be factored in when
completing the application. The full hourly rate is charged regardless of the of actual time the
facility is used (i.e. hours are not prorated). Rentals are available Monday through Sunday from
8:00 a.m. to midnight.
2. Rental Space: Use of space outside of the rented area or use of equipment not approved is
prohibited.
3. Responsible Person: Each rental will have a named Responsible Person who will be present
during the rental. The Responsible Person agrees to the Actions Required of the Responsible
Person and Rental Terms and Conditions. The Responsible Person must be 18 years or older.
Proof of age may be required.
4. Rental Scheduling: Rental space is scheduled on a first come first served basis. Reservations can
be made up to 12 months in advance, with the exception of rental requests for the Assembly
Room, which may be made up to 24 months in advance. Room Use and Rental Applications must
be submitted at least 5 business days before the requested rental date.
5. Reservation Confirmation: The facility is not considered reserved until the Senior Center has
received:
a. A complete Room Use and Rental Application/Letter of Agreement that has been signed by
the responsible person and the Senior Center Coordinator
b. The full damage deposit
c. A signed Administrative Rules for the Use of Alcohol
d. Evidence of insurance for events with alcohol
e. Rental Fee Due: Rental fees must be paid no less than 60 days prior to the rental or
immediately if rental is occurring in less than 60 days.
6. All activities held at the Senior Center must comply with Senior Center policies and City of Iowa
City Resolutions and ordinances.
7. Alcohol: Wine and beer may be served only in accordance with the Administrative Regulations
for the Use of Alcohol attached.
8. Refreshments: Arrangements can be made to serve refreshments in all rental spaces except
rooms 103 and G13.
9. Special Equipment: No special equipment may be used without Senior Center approval.
10. Property Damage: The rental permit holder is responsible to pay for all property damage to the
facility resulting directly or indirectly from the conduct of any group member or invitees,
including catering staff. Children must be supervised at all times.
11. Publicity and Content: Publicity for all events is the responsibility of the renter and must not be
intrusive to participants or disrupt Senior Center programming or operations. The Senior Center
neither approves nor disapproves the content, ideas, or subject matter presented during a
rental. The Senior Center does not accept responsibility for ensuring accuracy or that all points
of view are represented.
12. Collection of funds: Fundraising, charging of admission, and/or sale of items or services are not
allowed without Senior Center coordinator approval. Additional fees may apply:
a. Individuals, community groups, and for-profit organizations and businesses collecting funds
will pay two times the established rental rate.
b. 501c3 non-profit organizations collecting funds will pay two times the non-profit rental rate.
c. Political candidates and political parties conducting for-profit activities will pay the established
rental rate.
d. Government Entities wanting to collect funds will work with the Senior Center on a case by
case basis.
13. Access to rental space: Access to the rental space is provided by a computerized door locking
system that is set to automatically open and close specific areas of the building in accordance
with the needs identified in the rental request.
14. Set- up, Decorations: No set-up is allowed prior to the “start time” listed on the Rental
Application/Letter of Agreement. Only freestanding decorations are permitted, although tape
and suction cups may be used on windows. Use of the following items are prohibited: candles,
Chinese lanterns, tacks, nails, staples, rice, birdseed, glitter, silly string, and real rose petals.
Evidence that any of these items have been used may result in deduction from the rental
deposit. All decorations must be removed from the facility upon completion of the event.
15. Rental Checklist: A rental checklist is attached. The checklist includes the following:
a. Emergency contact phone numbers
b. Electronic door locking information
c. List of additional items that the Senior Center will provide beyond standard equipment. (e.g.
Additional chairs or large trash barrel)
d. Rental Completion Checklist
16. Rental Deposit: Use and Refund
a. A damage deposit is required for each rental in the amount set forth above. The renter shall
be responsible for any and all damages, including those damages not covered by the
damage deposit, caused by the renter or any guests or agents, all in accordance with these
Rental Terms and Conditions.
b. Where the renter has timely left the premises in a damage-free, clean condition, the City
shall return the full deposit to the renter within 30 days of the rental.
c. Where the renter fails to complete the Cleaning and Building Walk Through checklist, the
City reserves the right to retain all or a portion of the deposit to cover its costs in cleaning
the facility to its satisfaction. The City shall refund any remaining deposit to the renter
within 30 days after the events, along with an accounting of the amounts deducted from the
deposit.
d. Where the cost to repair, replace, or clean the facility, equipment or other property lost or
damaged during the events is greater than the deposit, the renter shall be responsible for
paying the excess costs, as determined solely by the City, which will be charged to the
renter’s credit card. The City shall notify the renter of such expense prior to charging the
credit card.
e. If the renter fails to clean and exit the facility prior to the end time listed on the Rental
Terms and Conditions, the renter will be charged for the additional time at the full hourly
rate, which shall be deducted from the rental deposit.
17. Cancellation Policy: Cancellations should be made at the earliest possible date. The deposit will
be forfeited if a rental is cancelled within 5 business days of the rental date. The deposit and
rental fees will be forfeited if a rental is cancelled within 2 business days of the event date. To
cancel a rental the responsible person must speak directly with a Senior Center staff member. In
the event of unforeseen circumstances beyond the City’s control, the City reserves the right to
reschedule and/or cancel the building reservations. All deposits and payment made will be
refunded in full to the renter.
18. Maximum Attendance: Each rental space in the Senior Center has a maximum capacity. The
Responsible Person is responsible for all guests on the premises and shall assist the Senior
Center in enforcing this limitation. In the event that the Senior Center believes that the
maximum capacities (listed below) have been exceeded, guests will be asked to leave or may be
refused entrance. The maximum capacity for the rental spaces in the building are as follows:
- Assembly Room: 225; Room 202: 50; Room 205: 15; Room 208: 25; Room 209: 15; Room
103: 15; Room G13: 15
Rental Application
Applicant Name: ____________________________________________________________
Is this a 501c3 non-profit organization? Yes _____ No _____
Address: ___________________________________________________________________
Phone Number: _________________________ Email Address:_________________________
Information for Responsible Person who will be present:
Name: _____________________________________________________________________
Address: ___________________________________________________________________
Primary Phone Number: ___________________ Secondary Phone Number: ______________
Email Address: ________________________________________ Birthdate: _______________
Event Name: _______________________________________________________________
Date of Use: ____________________________________________________________
Rental Start Time: __________AM/PM Rental End Time: __________AM/PM
Total Hours Requested: _________
Room Requested: ___________________
Estimated Attendance: _______________
Will food and/or non-alcoholic drinks be served? Yes _____ No _____
Would you like permission to serve alcohol during the rental? (Restrictions apply. See
Administrative Regulations for the Use of Alcohol attached) Yes _____ No _____
Will you be hiring a caterer for the event? Yes _____ No _____
Catering Company: ______________________
In the event that you receive permission to serve alcohol, will the caterer be providing the
alcohol? Yes _____ No _____ (If yes, please provide a copy of the caterer’s liquor license)
Is Audio/Visual equipment needed? Yes _____ No _____
If yes, please list equipment needs: _______________________________________________
Would you like permission to fundraise, charge admission, and/or sell items or services
during your event? Yes _____ No _____
Explain_______________________________________________________________
Will you be renting special equipment from a third -party vendor? Yes _____ No _____
Explain_______________________________________________________________
Actions Required of Responsible Person
This Letter of Agreement designates the responsible person(s) who accept(s) the following
responsibilities. The responsible person:
1. Must be 18 years of age or older or 21 years of age or older if alcohol is being served;
2. Reads and agrees to the Terms and Conditions for Rentals (included below);
3. Oversees security and safety in the approved area(s) of the building for the duration of
the rental;
4. Takes a leadership role in any emergency occurring while the space is being used and
reports emergencies to staff;
5. Participates in required room use training;
6. Monitors and secures the facility after the program ends;
7. Operates audiovisual equipment;
8. Manages the set-up and clean-up of the rented space;
9. Reports cancelations.
Agreement and Indemnification Signatures
1. (Only applicable if the applicant is not an individual.) I acknowledge that I have the
authority to act on behalf of the group making the application.
2. Applicant agrees that the responsible person identified above has received and will
abide by the rules, policies, and conditions for use of the room, which are included in
this application.
3. Applicant waives, releases, and discharges the City and its officers, agents, and
employees from any and all claims for damages for personal injury, death, property
damage, any claim in tort, or any other claim, regardless of legal theory, that may accrue
as a result of the use of the room. This waiver includes but is not limited to any
negligent acts or omission of the City. In no event shall the City or its officers, employees
or agents, be responsible or liable for any direct, indirect, special, incidental, or
consequential damages; lost profits; or any other economic or physical loss or damage
to any individual regardless of legal theory resulting from participation in the use of the
room.
Applicant agrees to indemnify and defend, at Applicant’s own cost, the City of Iowa City
and its directors, officers, employees and agents from any claims, demands, damages,
rights of action or causes of action present or future whether the same be known or
unknown, anticipated or unanticipated, brought against any or all such persons or
entities based on the Applicant’s use of the room.
By approving this application, Applicant acknowledges and agrees that the City of Iowa
City is not waiving any immunity.
________________________________ _________________
Signature of Applicant Date
Iowa City Senior Center Rental Check List
Senior Center Address: 28 S Linn St, Iowa City, IA 52240
Applicate Name/Event Name:_________________________ Room being rented:___________________
Senior Center Emergency Phone Numbers: _________________________________________________
____________________________________________________________________________________
Exterior Doors
Washington St (ground floor) door
Linn St (1st floor) door
North Ramp (1st floor) door
Skywalk (2nd floor) door
Propping open doors is prohibited under any circumstances due to fire code.
Interior Spaces
Ground Floor
1st Floor
2nd Floor
List of items that will be made available for the rental:
Rental Completion Checklist
Place all garbage in trash can, tie garbage bag, leave in the rental space
Place tables and chairs in original positions
Wipe off tables with provided towels and spray bottle
Remove all decorations, special equipment, or other items brought on-site
Check restrooms and hallways to confirm they are empty, turn off lights
Turn off lights and audiovisual equipment in rental space
Confirm all exterior doors are locked and latched at the end of the rental period
Report any emergencies that occurred to staff
IMPORTANT: The doors are on a scheduled electronic door system. Do not leave the facility before
all exterior doors are locked. You must confirm all people who attended your program have exited the
building after the doors have locked. You must confirm all of the exterior doors have latched.
THIS INFORMATION SHALL BE SHREDED IMMEDIATELY UPON FINAL RECONCILIATION OF DEPOSIT
DEDUCTIONS
CC Number:____________________________ Exp. Date:_______________
Authorization code:__________
FOR ADMINISTRATIVE USE ONLY
Application Reviewed and Approved:
__________________________________________ ________________________
Coordinator Signature Date
Special Requests: The following special requests shown on the Application are hereby granted:
_____Use of alcohol _____Fundraise, charge admission, and/or sell items, or services
_____Use of special equipment
Additional: _______________________________________________________________
Room Rental Fee: ___________________
Received by: _________________________ Date:________________
Deposit Amount: _________________
Received by: _________________________ Date:________________
Returned to renter by: __________________ Date: ________________
Amount returned: $________________
Deductions from Deposit, if any:________________________________________________________
Signed Administrative Regulations for the Use of Alcohol (required for events with alcohol):
Received by: _________________________ Date:________________
Caterer liquor license (required for alcohol events where caterer is providing the alcohol)
Received by: _________________________ Date:________________
•
•
•
•
•
•
•
•
•
•
•
•
•
•
QUESTIONS?
If you lose your card or have a question about your
card and cannot find the answer in this brochure or
online, then call or email the City of North Liberty.
Please leave a message with your name, a phone
number to reach you and a description of your
concern. Allow up to three business days to receive
a response.
(319) 626-5722
transit@northlibertyiowa.org
North Liberty City Hall
3 Quail Creek Circle
North Liberty, IA 52317
northlibertyiowa.org/transit
If you have a question about vehicles & accessibility,
then please call Yellow Cab of Iowa City.
(319) 338-9777 General Line
(319) 341-7939 NLTAP Line
yellowcabic.com
HOW TO BOOK A RIDE
Call Yellow Cab of Iowa City at
(319) 341-7939 no less than 30 minutes
prior to requested ride. When selecting a
time, keep in mind that Yellow Cab driver
will not wait more than five minutes for
passengers to arrive.
Tell the scheduling operator you would like
to book a ride under the North Liberty
Transportation Assistance Program,
the total number of passengers, whether
you require an accessible vehicle, and the
intended eligible destination (i.e. name of
medical office, pharmacy, etc).
At the start of each ride, the Yellow Cab
driver will collect the $1 fare per ride and
use your card to verify eligibility and fill out
a ride report. To ride, card holder must have
weight appropriate, unexpired car seats for all
children 5 years old and under. Cardholders
who do not have their card will be denied
a ride.
$1 fare
USER GUIDE
Version: 2019.12
YELLOW CAB
(319) 338-9777 GENERAL LINE
(319) 341-7939 NLTAP LINE
Transportation
Assistance
Program
(NLTAP)
Rides must originate from or arrive at one of the
following locations:
• North Liberty Community Pantry
• North Liberty Community Center
• Grocery Stores: North Liberty Fareway, Coralville
Aldi or Crosspark Road Hy-Vee only
• Medical Offices located within North Liberty,
Coralville, Iowa City or Tiffin, for verifiable
appointments
• Pharmacies and Durable Medical Equipment
Suppliers: must be located within North Liberty,
Coralville, Iowa City or Tiffin
• Banks and Credit Unions: must be located within
North Liberty
• Government Offices, including North Liberty
City Hall, North Liberty Police Department,
North Liberty Fire Department, North Liberty
Post Office, Social Security Administration
(local office), Iowa Drivers License Station (local
office), Johnson County Administration Building
or Johnson County Health and Human Services
Building only
• Bus Stops: CAMBUS Research Park stops,
Coralville Bus Heartland stop or Coralville Bus
Coral Ridge Mall stop only
• Other Medical Transport Stops: intermediate
connection to third party medical transports
• Cardholder address as printed on front of card
USAGE RESTRICTIONS
Ways the North Liberty Transportation
Assistance Program cannot be used:
• NLTAP card cannot be used in place of an
official federal or state ID (i.e. to obtain
a passport, board an airplane, prove
employment eligibility, vote or verify age
for alcohol or cigarette purchases).
• Travel cannot be provided to unapproved
locations.
• As work or school transportation.
• For rides with less than a 30-minute notice.
• In the event of a medical emergency, you
must call 911.
What happens if I try to use the
program incorrectly or produce an
invalid card?
• Driver will retain the card being used and
refuse your ride. You should call the City
of North Liberty (contact information on
other side of brochure) if you feel that
your card has been retained in error.
• If an emergency medical situation is
suspected, the driver will call 911 and the
person listed as the emergency contact
on the card.
• The City of North Liberty will
review individual transportation use
records on a monthly basis. Staff will
contact cardholders in the event that
unapproved use is suspected.
Cardholder is
responsible for
paying
$1 fare per ride.
Payment must
be made to the
driver at time of
pickup.
Riders and drivers are expected to behave
in a respectable manner. Disruptive, abusive,
or argumentative riders will be asked to leave
the vehicle and reported to the City. If you
have an incident or concern with a driver,
please report it to Yellow Cab of
Iowa City at (319) 338-9777.
Please exhaust any available alternative modes
of transportation before using NLTAP.
Rides must be scheduled to take place:
Monday through Friday 7 a.m. to 10 p.m.
Saturday 7 a.m. to 7 p.m.
Rides will be given to:
• Cardholder plus dependents (names must be
listed on back of card)
• Cardholder plus one friend or family member
• Cardholder plus one personal care attendant
and one friend or family member
Dependents not allowed to ride without cardholder.
All riders must have same origin and destination.
WHAT IS NLTAP?
The purpose of the North Liberty Transportation
Assistance Program, or NLTAP, is to assist residents
who may ― for various reasons ― be unable to
travel to important destinations in and near North
Liberty for essential quality-of-life services.
For eligibility details and necessary
documentation, refer to the program application
online at northlibertyiowa.org/transit or in print at
North Liberty City Hall, 3 Quail Creek Circle, North
Liberty, IA 52317.
HOW CAN AN NLTAP CARD BE USED?
TRANSPORTATION
ASSISTANCE
PROGRAM
Pass Application Form
APPLICANT IDENTIFICATION INFORMATION
PURPOSE
The focus of the City of North Liberty Transportation Assistance Program (NLTAP) is to
assist eligible residents who may - for various reasons - be unable to travel to important
destinations in and near North Liberty for essential quality-of-life services.
NAME
HOME ADDRESS
NORTH LIBERTY, IA 52317
BIRTH DATE
PHONE #
E-MAIL optional
Must provide one of the following proof of identification photo documents (current and not expired):
• U.S. Driver’s License
• U.S. Non-Driver’s ID card
• U.S. or foreign Passport
• U.S. Permanent Resident card
• Johnson County Iowa Community ID
• Consular IDMust provide one of the following proof of residency documents with applicant name and home address:
• Utility bill (dated within last 30 days);
• Insurance bill (dated within last 30 days);
• Bank statement (dated within last 30 days);
• Employment pay stub (dated within last 30 days);
• Local property tax statement (dated for present year);
• Mortgage payment receipt (dated within last 30 days);
• Voter registration card (current);
• Jury summons or court order issued by a state or federal court (dated within last 30 days);
• Rental agreement (dated for present year);
• Mobile home lot payment receipt (dated within last 30 days); or
• Vehicle registration (dated for present year).
PREPARER’S NAME
RELATIONSHIP TO APPLICANT
If applicant required the assistance of a preparer to fill out application, complete the information below.
Email
transit@northlibertyiowa.org
Website
northlibertyiowa.org/transit
Administration
(319) 626-5722
E-MAIL optional
TRANSPORTATION
ASSISTANCE
PROGRAM
Pass Application Form
IF APPLICANT HAS LEGAL DEPENDENTS
under 18 years old
Must be legal dependent(s) of applicant and provide documentation of dependent status (for example, a birth certificate). Dependents must ride with eligible adult; cannot ride alone. Vehicle size will limit the number of dependents that can safely ride with the applicant for each trip. Vehicles are not equipped with child seats. Applicant must provide a size appropriate, unexpired child restraint system for any rider six years old and under; must be a rear facing child restraint system for any child less than one year old and weighing less than 20 pounds.
NAME
BIRTH DATE1
NAME
BIRTH DATE2
NAME
BIRTH DATE3
TRANSPORTATION NEEDS ASSESSMENT
DOES APPLICANT RECEIVE OTHER TRANSPORTATION ASSISTANCE?Y N
IF YES, LIST ASSISTANCE SERVICES.
EMERGENCY CONTACT INFORMATION
NAME
PHONE #
RELATIONSHIP TO APPLICANT
NAME
BIRTH DATE4
APPLICANT’S PREFERRED PRONOUNS
SHE/HER/HERS HE/HIM/HIS OTHER _____________THEY/THEM/THEIRS
TRANSPORTATION
ASSISTANCE
PROGRAM
Pass Application Form
ELIGIBILITY INFORMATION complete one box
OPTION C DISABILITY PERMANENT o r D TEMPORARY
IS THE NATURE OF THE MEDICAL
CONDITION TEMPORARY OR PERMANENT?TEMPORARY PERMANENT
IF TEMPORARY, DATE CONDITION IS EXPECTED TO RESOLVE.
Y NDOES APPLICANT HAVE A MOBILITY AID?
IF YES, DESCRIBE.
DOES APPLICANT HAVE A MEDICAL CONDITION (PHYSICAL OR
MENTAL) WHICH CONSTITUTES A SUBSTANTIAL HANDICAP?Y N
Must provide note from physician attesting to the following answers. If necessary, new applicants may receive a temporary transportation pass valid for 30 days to allow for the note to be obtained.
OPTION A NO PERSONAL VEHICLE
DOES APPLICANT OWN A VEHICLE, REGISTERED IN THEIR NAME?Y N
IF YES, WHY IS APPLICANT UNABLE TO USE THIS VEHICLE?
OPTION B INCOME STATUS
Must provide official documentation for any benefits or income listed below.Date on documentation must be within the past two months.
APPLICANT’S HOUSEHOLD RECEIVES THE FOLLOWING. Check all that apply.
SNAP (FOOD
ASSISTANCE PROGRAM)
TANF (TEMPORARY ASSIST
NEEDY FAMILIES)
WIC (WOMEN, INFANTS & CHILDREN)
PUBLIC HOUSING
VOUCHER (SECTION 8)
FIP (FAMILY INVESTMENT PROGRAM)
LIHEAP (LOW INCOME
ENERGY ASSISTANCE)
MEDICAID or MEDICARE
CHILDCARE VOUCHER
OTHER If applicant does not currently receive
any of the above assistance, then they
could qualify based on annual gross
income. Limit is set at 185% of the
Federal Limit, but not exceeding 85% of
the North Liberty Median Income from
the most recent census.
Household Size Gross Annual Income
1 $23,106
2 $31,283
3 $39,460
4 $47,637
5 $55,814
TRANSPORTATION
ASSISTANCE
PROGRAM
Pass Application Form
OTHER RESOURCES AVAILABLE:
Elderly Transportation AssistanceRSVP through United Way of Washington & Johnson Counties unitedwayjwc.org or (319) 338-7823TRAIL of Johnson County trailofjohnsoncounty.org/ or 319-800-9003Assistance in Buying a CarCharity organizations FreeCharityCars.org or 1-800-CharityCarsLocal Transit Referrals, Education, Outreach, and Awareness Johnson County Mobility Coordinator johnson-county.com/mobility or 319-356-6090Johnson County SEATS johnson-county.com/SEATS or 319-339-6127Need a Car Seat or Learn How to Properly Install One?Community Partnerships for Protecting Children johnson-county.com/ss/cppc or 319-339-6179 North Liberty Police Department 319-356-6800 (non-emergency number)
The undersigned applicant (the “Applicant”) authorizes the City of North Liberty, Iowa, to contact any service or benefit providers indicated in this application for the purpose of verifying the documentation provided, and to verify Applicant’s eligibility for the North Liberty Transportation Assistance Program (“NLTAP”).
Applicant agrees that membership in NLTAP, if approved, is effective only for the period that the applicant qualifies to receive services, and that membership in NLTAP must be renewed on an annual basis or upon termination date of a temporary pass, whichever happens first.
Applicant understands and agrees that the City of North Liberty may terminate the Transportation Assistance Program for any reason. In the event the Transportation Assistance Program is terminated, the City of North Liberty will mail a written notice to the address on this application at least 10 days prior to the termination date. Applicant hereby specifically waives any claim or cause for damages resulting from the cancellation or discontinuation of the Transportation Assistance Program.
By submitting this application, the Applicant attests that all statements on this application are true and correct, and agrees that intentionally false statements made on this application will be grounds for the City of North Liberty to deny the application or to cancel Applicant’s membership in NLTAP.
Applicant agrees that they have reviewed the NLTAP Program Information, Cardholder User Guide, and Code of Conduct documents, and agrees to abide by the terms contained therein, including all program rules and restrictions as may be modified from time to time.
Applicant acknowledges that NLTAP passes are for the exclusive use of NLTAP members, and may not be shared. Applicant agrees that, if applicant’s pass is lost or stolen, to the applicant will report that loss immediately. Applicant understands that violation of any of these terms will result in the immediate cancellation of Applicant’s membership in NLTAP.
If this application is signed by a preparer (“Preparer”) on behalf of the Applicant, Preparer affirms that Applicant understands and agrees to the terms of membership described in this application, and that the application was prepared at Applicant’s direction.
PRINT APPLICANT’S NAME
APPLICANT’S (OR PREPARER’S) SIGNATURE
DATE
It is the policy of the City of North Liberty, Iowa, not to discriminate on the basis of race, color, national origin, sex, disability, religion, creed, age, marital status, sexual orientation, and gender identity in its programs, activities, and employment practices. If you have questions related to this policy, please contact Human Resources Director Deb Hilton at dhilton@northlibertyiowa.org or (319) 626-5700.
CONSENT, ACKNOWLEDGEMENT, AND AUTHORIZATION
TRANSPORTATION
ASSISTANCE
PROGRAM
Frequently Asked Questions
Why do we have our own Yellow Cab phone number? To provide our cardholders with a more responsive
service, Yellow Cab reserved a new phone line for our users... 319-341-7939. Only NLTAP cardholders in good
standing can use this line. If the NLTAP line is busy, please understand that one of your fellow North Libertarians is
on the phone booking a ride, so be patient & keep trying. You are also welcome to call their general line at 319-338-
9777.
When can I pre-schedule a ride? Rides scheduled ahead of time for a particular day & time are called “timed
rides.” NLTAP cardholders can reserve a timed ride for verifiable medical appointments (i.e. primary care physicians,
psychiatrists, chiropractors, physical therapists, optometrists, dentists, and other medical professionals) up to 24
hours prior to the appointment time. Rides for any other purpose must be scheduled at the time of need, giving
Yellow Cab a 30-minute window in which to pick you up.
How early in the day can I contact Yellow Cab dispatch? Phone lines to schedule an NLTAP ride are open from
7:00 AM to 10:00 PM Monday through Friday, and Saturday from 7:00 AM to 7:00 PM.
Will the driver wait for me while I run into my destination? No. You need to book each trip separately.
What is the NLTAP Code of Conduct? The NLTAP Code of Conduct is a set of rules for ridership which are
intended to promote the safety and welfare of NLTAP members. Use of NLTAP requires abiding by the Code
of Conduct. A copy of this document is provided to every cardholder and can also be found online 24/7 at
northlibertyiowa.org/transit.
What should I do if I suspect Yellow Cab dispatcher or driver misconduct? Report the issue immediately to the
City of North Liberty via email at transit@northlibertyiowa.org or leave a message at 319-626-5722 (only if email is
not an option).
What if I/my driver makes a mistake and I get dropped off at the wrong location/an unapproved location?
Will Yellow Cab pick me back up? No. Yellow Cab dispatchers will not book a ride to pick you up from an
unapproved location. NLTAP cardholders are expected to understand the limitations of the program and will have
to arrange for alternate transportation if they end up in the wrong place. Detailed information is available in the
NLTAP User Guide, online 24/7 at northlibertyiowa.org/transit, and other questions can be addressed to transit@
northlibertyiowa.org at any time.
It might take me more than five minutes to get from my home to the taxi cab. The cab driver will only wait five
minutes. If you do not show immediately, a Yellow Cab dispatcher will give you a courtesy call. If dispatch cannot
reach you by phone, then they will tell the cab driver to leave. If you live with personal mobility issues, you should
communicate that information to the Yellow Cab dispatcher when you book your ride. If you have booked a timed
ride, please make sure you are at the front door ready for your scheduled time.
Can I use this service to get to work or school? No. Your NLTAP card cannot be used for work or school trips.
What if the transportation program or Code of Conduct changes? You will be notified of major changes to the
program (approved destination edits, new restrictions, etc) by postal mail and email (for persons who submitted an
optional email address). Minor changes to the program will be communicated electronically and available for review
online 24/7 at northlibertyiowa.org/transit.
What if I move outside of North Liberty? NLTAP is a program for North Liberty residents only.
NORTH LIBERTY TRANSPORTATION ASSISTANCE PROGRAM (NLTAP)
TRANSPORTATION
ASSISTANCE
PROGRAM
What if I move to a new location in North Liberty or to a different apartment in my building? Please notify
City staff so your card and contact information can be updated. Send an email to transit@northlibertyiowa.org
or leave a message at 319-626-5722. You will not need to reapply in full or take a new photo, but you will need to
reestablish proof of residence by furnishing a piece of official mail, mortgage document, or rental agreement with
your new address on it.
If you lose your card or still have unanswered questions about program details, call or email the City of North
Liberty. Please leave a message with your name, a phone number to reach you, and a description of your concern.
Allow up to three business days to receive a response.
(319) 626-5722
transit@northlibertyiowa.org
North Liberty City Hall, 3 Quail Creek Circle, North Liberty, IA 52317
northlibertyiowa.org/transit
If you have a question about vehicles & accessibility, then please call Yellow Cab of Iowa City.
(319) 626-9777 General Line
(319) 341-7939 NLTAP Line
yellowcabic.com
Version: 2020_02
Frequently Asked Questions
NORTH LIBERTY TRANSPORTATION ASSISTANCE PROGRAM (NLTAP)
You have applied for a North Liberty Transportation Assistance Program (NLTAP) card under
Option C: Permanent Disability or Option D: Temporary Disability. The application you filled out
specifies that a note from your physician is required to receive NLTAP service under Option C or
Option D. Please have your physician fill out the following verification letter attesting to the
presence of a handicap. We do not need details about the condition or any other private medical
information. This letter should be returned to the City of North Liberty (C/O Angela McConville,
3 Quail Creek Circle, North Liberty, IA 52317) within 30 days of receiving a NLTAP card or your
privileges may be limited or revoked.
Patient Information
Name: ______________________________
Date of Birth: ______________________________
Address: ______________________________
------------------------------------ TO BE FILLED OUT BY PHYSICIAN ONLY ------------------------------------
Physician Information
Name: ______________________________
Clinic: ______________________________
Phone #: ______________________________
Please initial below where applicable:
I confirm that this patient has a medical condition (physical or mental) which
constitutes a substantial handicap (including procedures which will impact their
ability to drive).
The nature of the medical condition is permanent.
OR
The nature of the medical condition is temporary.
Patient can resume driving on ______________________________ (date).
Signature: ______________________________
Date: ______________________________
TRANSPORTATION
ASSISTANCE
PROGRAM
Authorization for the Release of Information
FOR VERIFICATION OF PROGRAM PARTICIPANT STATUS
I authorize the City of North Liberty to release to the Johnson County Treasurer’s Office, the Johnson County
Social Services Department, the Iowa Department of Human Services, my current landlord, and/or the Social
Security Administration confidential information pertaining to my eligibility for the specific programs I have
indicated on the North Liberty Transportation Assistance Program application and also circled below.
I authorize the Johnson County Treasurer’s Office, the Johnson County Social Services Department, the Iowa
Department of Human Services, my current landlord, and/or the Social Security Administration to release to the
City of North Liberty confidential information pertaining to my eligibility for the specific programs I have indicated
on the North Liberty Transportation Assistance Program application and also circled below.
I also do hereby forever release and discharge the City of North Liberty, the Johnson County Treasurer’s Office, the
Johnson County Social Services Department, the Iowa Department of Human Services, my current landlord and/
or the Social Security Administration from any liability for divulging such information whether such information is
deemed confidential or not. A photocopy of this form shall be considered as acceptable as the original.
CURRENT LANDLORD
DATE
NAME
HOME ADDRESS
NORTH LIBERTY, IA 52317
PHONE #
SOCIAL SECURITY #
(USED TO VERIFY STATUS OF PROGRAMS)
OFFICE USE ONLY
In order to help the City of North Liberty detemine qualification for the North Liberty Transportation Assistance
Program, please verify this individual’s eligibility for the programs circled above. Thank you for your assistance!
CIRCLE PROGRAMS
TO VERIFY:
Childcare (Title XX)
FIP
LIHEAP
Medicaid/Medicare
Section 8
SNAP
SSDI
SSI
TANF
WIC
No vehicle registered under name.
Subsidized/income-based housing.
AUTHORIZED SIGNER
DATE
PROGRAM NAME
AGENCY STAMP
AUTHORIZED SIGNER
DATE
PROGRAM NAME
AGENCY STAMP
Please return addressed to the North Liberty Special Projects Coordinator, North Liberty City Hall, 3 Quail Creek
Circle, North Liberty, IA 52317. Questions? Email amcconville@northlibertyiowa.org or call 319-626-5722.
(ONLY IF APPLICABLE)
SIGNATURE