MEMORANDUM FOR TRAFFIC REGULATIONS
PROHIBITION AGAINST PARKING (Except for the Handicapped):
Street, etc:_South Clyde Avenue_
Location, etc:_No. 7632_(Permit No. 77492)_
Distance or extent:_g_
Hours:_at all times_
Days:_no exceptions_
WILLIAM O'NEIL
MICHELLE A. HARRIS Alderman, 8th Ward
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
77492
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
3. Drivers License Number
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4. Applicant Last Name
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First Name
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5. Home Address (primary residence)
STREET NUMBER j DIR. j STREET NAME
6. Address where signs wiffbe postea
6. Address where signs wince posted
STREET NUMBER I DIR. I STREET NAME
■ WARD NUMBER
7. Phone Numbers
7 I 7 I 3 1,-3 17 ly \SL If
8. Current Permanent Disabled Placard Number
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Business
7 17
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8. Current Permanent Disabled Placard Number
Registered to
Relationship to Applicant
Current License Plate Number
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Registered to
City Sticker No.
Relationship to Applicant
10. Description of Medical Condition and Disability
11 y
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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 (i.e., garage, car port, driveway, etc.)?
S YES □ NO
12.11 you answered Yes to question 11,-please describe:
£3 Garage; □ Driveway; □ Car Port; □ Other:
□ Yes;
^ No. Please explain:
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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.
Signature
FOR OFFICE USE ONLY
□ FEE
□ PLACARD/PLATE □ RESIDENCY
□ COMPLETE
Disabled Parking Application Payment Stub
Please make check or money order payable to the City of Chicago or
when paying with a credit card, please fill in the following information.
THIS PAYMENT WILL NOT BE PROCESSED IF NOT SIGNED
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PLEASE:
• DO NOT jend cash
• DO NOT fold Ihe payment sturjfs)
• DO NOT staple the check or money order to the
TOTAL AMOUNT DUE
70.00
PAYMENT AMOUNT ENCLOSED
Male 5 09" 230 lbs HZL Eyes
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