490-002 12/27/05
APPLICATION FOR DISABLED PARKING SIGNS 78048 - PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
An application will not be considered complete unless:
All lines of the application have been completed in full;
A check or money order for $70.00 made payable to the City of Chicago is submitted as payment of the application fee; Please note: The application fee shall be waived for any person holding a valid, current disabled veterans plate.
Disability must be permanent as evidenced by a copy of your valid disabled placard and/or current vehicle registration submitted at the time of application;
Proof of residency, in the form of a copy of your drivers license, state identification, or utility bills are submitted at the time of application.
Completed application forms may be returned to: the office of your alderman, any City of Chicago Department of Revenue facility, or via mail at P.O. Box 803100, Chicago, IL 60680-3100, ATTN: Disabled Permitting Section. A $25.00 maintenance fee will be billed to you annually. Should you have questions or concerns, please call our permit processing division at 312-744-PARK (7275).
1. Date of Birth 2. State Identification Number MO _ DAY _ YEAR 0\ g | 0 \ 3 | Ur\% | | | | | | | | | | | \ |
3. Drivers License Number Pi i \ x\6\\\\ci\^\\^^\2>\'2-\$' |
4. Applicant Last Name PlftlPlPlftlSl I I I t I..... |
Ml M |
-1-1-^i-1-1-:-1--=-'-1-- First Name iJltflflM J 1 1 1 1 L L_ |
5. Home Address (pri STREET NUMBER 3IHI248I |
mary DIH. a |
residence) STREET NAME II ZIP CODE R|u|T|H|£|R|!^|fqD| I I I I I I I I U\o\^\3\¥- |
6. Address where sig STREET NUMBER 3\L±\Z\Z,\ |
ns w DIR. N |
II be posted STREET NAME Qui \T\H\£\K\l-\o\f^ |
WARD NUMBER I I I I I I I I I I I £ |
7. Phone Numbers Home 1 I 7 I 3 T7 I 7 \'7 T$H cl |
7 | S |
Business I I 7 I I T I I I |
8. Current Permanent Disabled Placard Number US I XW3 |
Registered to |
Relationship to Applicant |
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- -J-:-1■-^- |
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9. Current License Plate Number £7£77 |
Registered to |
City Sticker No. |
Relationship to Applicant |
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10. Description of Medical Condition and Disability |
Alternative Parking: Please note your application may be denied if you have alternative accessible off-street parking options. |
11. Is there off-street parking available at your primary residence S YES □ NO (i.e., garage, car port, driveway, etc.)? |
12. If you answered Yes to question 11, please describe: 53 Garage; □ Driveway: □ Car Port; □ Other: |
1-5 Is vour off-street oarkina accessible? To K ^ rvv 'Zo U-> vo, lW to Tm c C, rt£-J°,C,£ frt~So ~jZ 13. your oft street parking accessible. \? rL." - t-i-** S>TfLe*C,rH to L->*t th e>°**- W tc^ □ Yes; SI No. Please explain: f ^ ^ ^^^^ A//^ ^ Use My r,^,f |
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14. Affirmation: I hereby affirm that the above information is true and correct. If the City of Chicago Department of Revenue determines that the applicant has falsely represented one or more of the above conditions, the applicant shall be subject to a fine of not less than $100 but no more than $500, and the application shall be denied. I also understand that it is my responsibility to notify the Department of Revenue of any changes in the information provided.
H- ^0^9^_ Date
-1-'--
=OR OFFICE USE ONLY
□ FEE □ PLACARD/PLATE □ RESIDENCY □ COMPLETE