HomeMy WebLinkAboutReduced fare 31-day bus pass
IOWA CITY AND UNIVERSITY HEIGHTS CORPORATE RESIDENTS ONLY
(Applicant must return completed form to DHS at 855 S. Dubuque St.
or to Social Security at 400 S Clinton St./2nd Floor for verification of income)
Free Elderly Low Income Off-Peak Bus Pass
(must be age 60 and over, and low income plus)
Include proof of age, i.e. copy of Driver’s License/Birth Certificate
- or -
Reduced fare 31-Day Bus Pass
Include proof of residence, i.e. copy of utility bill
AUTHORIZATION FOR RELEASE OF INFORMATION I authorize the City of Iowa City to release to the Department of Human Services-Johnson County and/or the Social Security Administration, and I authorize the Department of Human Services-
Johnson County and/or the Social Security Administration to release to them, confidential information pertaining to my eligibility for the programs listed below:
Food Stamp Program FIP (Family Investment Program)
Title XX (Child Care Assistance) SSI (Supplemental Security Income)
City of Iowa City Utility Discount Program utility account number
Assisted Housing program = $15,950 maximum annual income (for one person).
I also do hereby forever release and discharge the City of Iowa City, the Department of Human
Services-Johnson County and 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. This release expires 1 year after date of signature.
Please Print
Name: _________________________________ SS# (used to verify
status on above programs) ___________________
Address: _______________________________ Signature: ________________________________
City/State/Zip: ___________________________ Phone: _________________ Date: ______________
JOHNSON COUNTY HUMAN SERVICES OR SOCIAL SECURITY ADMINISTRATION USE ONLY:
I have enclosed verification of eligibility. Please verify this individual’s eligibility for the program(s)
listed above. Return this form by mail to Transportation
DHS Services, City of Iowa City, 335 E. Iowa Avenue,
Signature: Iowa City, IA 52240. Thank you for your assistance!
Date Verified: _________________________ I verify that the Applicant ___ does / ___ does not
receive any of the program benefits that are listed above.
SS Signature: _________________________ I verify that the Applicant ___ does / ___ does not receive
any of the program benefits that are listed above.
Date Verified: _________________________
11/2011 transit/forms/elderlyfreereducedfare.doc