Feb 04 2011
773-523-8440
77402
An
10:15PM HP LASERJET FRX
>appucation for disabled parking signs Please read the following carefully -4ep6re completing the form
application will lot be Sons^i^O complete unless: <*"0 I ii , All »ines of the application have been completed in full; jgw-^- %f "T"| K^<^. ■ A check or money order for $70.00 made payable to the City of Chicago is submitted as payment of the application fee; Please nole: 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 lorm of a copy of your drivers license, slate 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).
i. Date of Birth MO _ DAY YEAR il* ! ol 6 1 n 14 |
2. State Identification Number ! 1 1 T I i Mill |
3. Olivers License Number giai^Thiaid \n~^\3\^\°i |
4. Applicant Last Name iQohdmlflUni l 1 l 1 I l l l l |
Ml i First Name poisiei l I I i 1 M |
|
|
|
|
S. Home Address (primary residence)
STREET NUMBER
3HL517
STREET NAME 11
i zip cooe
Ml Mil I I 11 1 I, I 1 I
6. Address where signs will tie posted of. OoWdWi 3*VG~7 1*3 7»SrtX> SWeeV
/^TREET NUMBER I OIF. I STREET NAME Z3 «"*W«»»-|
7. Phone Numbers ' Home Business
01 O I a I K lo
i_La
8. Current Permanent Disabled Placard Number
3 IS
WARD NUMBER
Registered to
Relationship to Applicant
Registered to
{*. Current License PlateN umber
City Sticker No.
Relationship to Applicant
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 {i.e., garage, car port, driveway, etc.)?__
JSfcYES □ NO
12. tf you answered Yes to question 11, please describe:
□ Garage; □ Driveway; □ Car Port; □ Other
13. Is your off-street parking accessible? Of Yes; □ No. Please explain:
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 $50Q^twd tin anftlicaiion shall be denied. I also understand that it is my responsibility to notify the Department of Revenue of any chanp>»1ntne informartorTs|yovided.
Signature
Date
A-H-g
FOR OFF1
□ PLACARD/PLATE □ RESIDENCY
□ COMPLETE
Feb 04 2011 10:15PM HP LASERJET FRX
773-523-8440
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b 04 2011 10:15PM HP LASERJET FAX
773-523-8440
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JOSE GUZMAN
3457 W 38TH ST CWCAGO.U. 60632-3303
Registration 10: 53480592 PIN: 7102
2011 Illinois Registration identification Card
Jesse White, Illinois Secretary of State
ERT210/31/10:99:2513:99.00 EFT W-25B095 1K9567294 R 1011
Vehicle Veer 1999
Vehicle Msfce
CHRYSLER
Weight or CC's
Axles
Body Style 4 DOOR
LeasedJRerted Unit Number
Drivers License Numbers) or FEIN(e) G25542074349
Renewal Fee Due 99.00
2C3H046J4XH739168
Application Type
PERSON WITH DISABILITIES
File Number .
County COOK
103
Expiration Dele October 31, 2011
Plata Numoer W-25909S
Form Numoer: 114451577
This Identification Card must be carried at all times in those vehicles designed to carry more than 10 persons, or to pull or carry property, freight, or cargo; those that are designed or used for living quarters, and school buses (625 ILCS 5.3-416). If you travel outside Illinois, you may be required to exhibit this vehicle registration identification card as proof of ownership.
STICKER IHSTRilCTIONS
PLACE THIS VALIDATED DECAL ON YOUR REAR LICENSE PLATE
1. Clean the license plate by removing ail dirt, wax and tar.
2. Wipe dry.
3. Place renewal sticker on top of last year's sticker. Press firmly.
CAUTION: After sticker has been applied, it cannot be removed without destroying it.
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Please provide mandatory Insurance Information below.