HomeMy WebLinkAboutLow income elderly off-peak 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: ________________________________
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
W o r k e r Services, City of Iowa City, 335 E. Iowa Avenue,
Signature: Iowa City, IA 52240. Thank you for your assistance!
Date I verify that the Applicant ___ does / ___ does not
Verified: receive any of the program benefits that are listed above.
4/2010 transit/forms/elderlyfreereducedfare.doc