HomeMy WebLinkAboutForm 3_IC Bow Hunt Program Waiver of Separation FormIowa City Police Department | p: 319-356-5275 Form #3
410 E. Washington Street | Iowa City, Iowa 52240 Page 1 of 2
Iowa City Deer Management Bow Hunt Program
Waiver of Separation Requirement
Permission for hunting period: ____________________________
The City of Iowa City allows bow hunting of antlerless deer on private properties in the City of Iowa City,
Iowa (hereafter referred to as “City”). Among other requirements, Iowa City does not allow hunting within
150 feet of a home, building, or property line UNLESS the property owner or authorized manager of the
property waives that separation requirement in writing, and the waiver is filed with the City. The separation
requirement applies to homes, buildings, and property lines on the property being hunted as well as
homes, buildings, and property lines on adjoining properties.
This form shall be submitted to the City as evidence of a property owner’s w aiver of the 150-foot
separation requirement. The waiver applies only to the property described in this waiver; only to
the property owned by the person granting the waiver; and is subject to any and all conditions or
limitations listed in this waiver and set forth in “Application Process and Instructions; Rules; and
Additional Information.”
HUNT PROPERTY INFORMATION:
Owners of property being hunted
Street address of property being hunted
Mailing address of property owner if different from above including City, State & Zip Code
WAIVER INFORMATION:
Owners (or Property Manager) granting this waiver (Grantor)
Street address of property for which this waiver is granted
Mailing address of Grantor if different from above including City, State & Zip Code
Cell Phone Number of Grantor Email Address of Grantor
________________________________________________________________________________________________________
Emergency Contact Person and telephone number for Grantor
Expiration date of waiver:
(If no date is provided, this waiver applies to the entire hunting season, which ends 01/10/21)
Names of hunters this waiver applies to:
(“All” can be used to refer to all hunters having legal permission to hunt, or can restrict to certain individuals)
Limitations on waiver:
(“None” can be used, or the waiver can be limited, such as “Waive separation from garage and east side of house only”)
Iowa City Police Department | p: 319-356-5275 Form #3
410 E. Washington Street | Iowa City, Iowa 52240 Page 2 of 2
WAIVER INFORMATION (Continued):
If a property manager has signed this waiver rather than the property owner, evidence, satisfactory to the
City, must be attached to this form to show that the property manager is authorized to grant this wavier.
This waiver shall run until the expiration date unless the grantor rescinds this waiver in writing and files
the rescission with the City.
The City shall not be responsible for verification of ownership and the validity of signatures. Falsification
of this form shall subject the person submitting this waiver to prosecution under applicable laws and
statutes of the City and State of Iowa, and any hunter violating the separation requirements in the case of
an invalid waiver shall be subject to prosecution under other applicable laws and statutes of the City and
State of Iowa.
Property Owners (or Property Manager) Granting Waiver (Grantor): By signing this form I understand
that I am waiving the
200-foot separation requirement subject to any limitations I have listed in this form, for the persons and
period of time stated on this form.
Property Owner (or Property Manager) Signature Date
Property Owner (or Property Manager) Signature Date
Hunter Submitting Waiver Form: By signing this form I understand I am certifying the accuracy of the
information on this form and may be subject to prosecution for any false or inaccurate information. I also
am familiar with the boundaries of the property and structures to which this waiver applies, and that it
applies only the property for which this waiver has been granted.
Hunter’s Signature Date