APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
74514
An application will not be considered complete unless:
• ■ All lines of the application have been completed in full;
• A check or money orderfor $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 $25.00 maintenance fee will be billed to you annually. Should you have questions or concerns, please call our permit processing division at 312-744-PARK (7275).
1. Date of Birth
MO _ DAY
Oil I a i f
3 Ifc
2. State Identification Number
fell \X\®l5\6>\Z\o~G\6\l\G
3. Drivers License Number
Ado
4. Applicant Last Name
IfflftlAlVlgIS
Ml
First Name
5. Home Address (primary residence)
STREET NUMBER I DIR. I STREET NAME
mimiEi T<?\$\r\A\ 151T1
ZIP CODE
PllbTff7
6. Address where signs will be posted
STREET NUMBER DIR. STREET NAME
11913.161 \E\ 11I3IHJI IS in
„ WARD NUMBER
7. Phone Numbers
Home
h\ i irTai g ia ik
Business
8. Current Permanent Disabled Placard Number
3JS
Registered to
A/lf/TA R. fcraVA?.
Relationship to Applicant
9. Current License Plate Number
0 &3///a ^
Registered to City Sticker No.
Relationship to) Applicant
10. Description of Medical Condition and Disability ^^Li^$U4'^^ JjJ)®^ 'O-lo/O^ vJfotffh&SWfXj k&W Vtyze/S dr ki&k bloc I foe Ss in" e/i _
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.)?
YES □ NO
12.lfvou answered Yes to question 11, please describe:
^Garage; □ Driveway; □ Car Port; □ Other:
13. Isyour off-street parking accessible? M[ osT T(>IS§ pa.rki'A/c Sr>(W&> )'s /Vf US e ^ eU,«eAl<l »TKeir E>r OfYes; □ No. Please explain: W*-US« X (UxJT KToStk' v'&ry foJC>~
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.
Ail
FOR OFFICE USE ONLY
□ FEE □ PLACARD/PLATE □ RESIDENCY □ COMPLETE
REMOVE BEFORE VEHICLE IS IN MOTION. THIS PLACARD IS NOTTRANSFERABLE. FT IS ILLEGALTO COPY OR DUPLICATE THIS PLACARD.
' iTHE 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. SDRIVER'S LICENSE AND/OR REVOCATION OF.THE PLACARD. V ■ ■■: < ~ -y
PERMANENT