801597
490-002 12/27/05
APPLICATION FOR DISABLED PARKING SIGNS 74519 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
MO _ DAY
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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 DIR. STREET NAME
I ZIP CODE
6. Address where signs will be posted
STREET NUMBER
STREET NAME
., WARD NUMBER
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7. Phone Numbers
Home
Business
8. Current Permanent Disabled Placard Number
Registered to
Relationship to Applicant
9. Current License Plate Number
Registered to
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.
d2fX£S □ NO
11. Is there off-street parking available at your primary residence (i.e., garage, car port, driveway, etc.)?
12Jfyou answered Yes to question 11, please describe: £2fGarage; Q Driveway; □ Car Port; □ Other:
□ Yes; Please explain:
13.Is your off-streetparking accessible?
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
Date.
FOR OFFICE USE ONLY
□ FEE □ PLACARD/PLATE □ RESIDENCY □ COMPLETE
REMOVE BEFORE VEHICLE IS IN MOTION. THIS PLACARD IS NOT TRANSFERABLE. IT IS ILLEGALTO 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 $500 FINE AND SUSPENSION OF DRIVER S LICENSE AND/OR REVOCATION OFTHE PLACARD.
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PERMANENT
-LL 1106.
EXPIRES THE LAS
Jan. Feb. Mar. Apr. May June
/
CHARLES DAVIS JUSTINE DAVIS
8446 S. BENNETT AVE. CHICAGO, IL 60617
Pay to the Order, of
04-73
007436
2-50/710 IL 98213
Dollars fi aS-
Bankof America
ACH R/T 081904808
For_
i:0 7 50 5H □□□□□□ I.IDD i in-71. 3 g,
Harland Clarka
GUARDIAN SAFETY* BLUE