J90-002 12/27/05
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
An application will not be considered complete unless: VII 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. \J /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; \J 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. *a>-Q. ^/^-^OJT- f^7^
Completed application forms may be returned to: the office of your alderman, any City of Chicago Department of Revenye 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- 9 744-PARK (7275).
1. Date of Birth
MO _ DAY
2. State Identification Number
MW _ uni i i t^n _ _ / ■■ *
o ic \i ia i n i u \3Q t ufokfo\9\i\ i i ni <n »I a iy 4 & i Vi^i/ r7 r?
X. Applicant Last Name Ml First Name
4. Applicant Last Name
IN [X \fl
3. Drivers License Number
J~\ft yr\ \e \S
5. Home Address (primary residence)
STREET NUMBER DIR. STREET NAME
3 1SH/17I W\f\iWh\ \f\L\n \c \e
II ZIP CODE
6. Address where signs will be posted
STREET NUMBER DIR. STREET NAME
'ARD NUMBER
Mil
7. Phone Numbers
Home
Business
9 \7
3 I / |A I 51 o IS" I ^\S 17 13
8. Current Permanent Disabled Placard Number
Registered to CTtf m G S ^f/l- tJ i a
Relationship to Applicant
9. Current License Plate N
4R /C»&6 +
4ft
Relationship to Applicant
10. Description of Medical Condition and Disability $^J<ZCa.t f)\<? jOC Sut^rCeS
Alternative Panning: 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.)?
3)YES □ NO
12. If you answered Yes to question 11, please describe:
Garage; □ Driveway; □ Car Port; □ Other:
13. Is your off-street parking accessible? _ accede i A/ F Fo£- U)H£'£L £Hfl>£ # AM D PNC Please explain: ^ CH fi t ^ ^ ^
□ Yes;
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. vi
Signature
Date
cno nccirc i ice r»Mi v