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 $25.00 maintenance fee will be billed to you annually. Should you have questions or concerns, please call our permit processing division at 312-744-PARK (7275).
1. Date of Birth
MO _ DAY
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2. State Identification Number
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3. Drivers License Number
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4. Applicant Last Name
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First Name
5. Home Address (primary residence)
STREET NUMBER I DIR. I STREET NAME
mimiEi TZIP CODE
PllbTff7
6. Address where signs will be posted
STREET NUMBER DIR. STREET NAME
11913.161 \E\ 11I3IHJI IS in
„ WARD NUMBER
7. Phone Numbers
Home
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Business
8. Current Permanent Disabled Placard Number
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Registered to
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Relationship to Applicant
9. Current License Plate Number
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Registered to City Sticker No.
Relationship to) Applicant
10. Description of Medical Condition and Disability ^^Li^$U4'^^ JjJ)®^ 'O-lo/O^ vJfotffh&SWfXj k&W Vtyze/S dr ki&k bloc I foe Ss in" e/i _
Alternative Parking: Ple...
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