MEMORANDUM FOR TRAFFIC REGULATIONS
PROHIBITION AGAINST PARKING (Except for the Handicapped):
No. 6738 (Permit No. 117243)
Alderman, 50th Ward
APPLICATION FOR DISABLED PARKING SIGNS 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 lor 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, state issued medical card,
or the following utility bills: Peoples Gas, ComEd, or City of Chicago water bill 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 Finance 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).
2 State Identification Number
1 Date of Birth
MC DAY YEAR
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4 Applicant Last Name
3. Drivers License Number
First Name
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5 Home Address (primary residence) *
STREET NUMBER DIR STREET NAME
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7 Address where signs will be posted
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STREET NUMBER DIR STREET NAME
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3 Phcr.3 Numbers
9. Current Permanent Disabled Placard Number
J? J) 7 I ^
Relationship to Applicant
■SB lF
10 Current License Plate Number"of Vehicle that will be
parked in the space: P Q
Relationship to Applicant So ,J
11 Does the registered owner of the vehicle reside at the address of the applicant?
12 Provide a Description of Medical Condition and Disability /Jn-k^hs 21 Permanent disability □ Temporary
atiye ac □ NO
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Alternative Parking Please note your application may be denied if you have alternative accessible off-street parking options
□ YES
13. Is there off-street parking available at your primary residence
(i e., garage, car port, driveway, etc.)?
14.If you answered Yes to question 13, please describe the alternative parking available: □ Garage; □ Driveway, □ Car Port, □ Other
15. If alternative parking is available, why are you unable to access the space? Please explain-
□ YES ^
17 Are you able to walk 200ft?
16 Do you use assisted devices? ^ YES □ NO If yes, what type do you use? o r U^/^eY
NO lfno.why7M/<J <ft) % ^
Affirmation: Under penalties provided by law pursuant to Section 1-109 of the Code of Civil Procedure, I hereby certify and attest that the statements set forth in this document are true and correct I acknowledge that, pursuant to Section 1-21-010 of the Municipal Code of Chicago, persons who make material false statements on this application may be fined not less than $500 and not more than S1,000, plus three times the city's damages, litigation costs, collection costs and attorney s fees I acknowledge that providing false information on this application or omitting matenal information fiom this application may result in denial of the application I also understand that it is my responsibility to immediately notify the Department ot Finance of any changes iatfre-informatjon provided or I may be subject to a penalty of not less than S100 and not more than S500, under Section 9-64-050 (f) of the Municipal Code of Chicago.
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REMOVE BEFORE VEHICLE IS IN MOTION.
THIS PLACARD IS NOT TRANSFERABLE. IT IS ILLEGAL TO COPY OR DUPLICATE THIS PLACARD.
THE AUTHORIZED HOLDER MUST BE PRESENT AND MUST ENTER OR EXIT THE VEHICLE AT THE TIME THE PARKING PRIVILEGES ARE BEING USED. UNAUTHORIZED USE MAY RESULT IN A S500 FINE AND SUSPENSION OF DRIVER'S LICENSE AND/OR REVOCATION OF THE PLACARD.
PERMANENT
EXPIRES THE LAST DAY OF:
V