APPLICAnON FOR DISABLED PARKING SIGNS 768^79 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 fie; Please note: The application fee shall be waived for any person holding a valid, current disabled veterans plale. J
• 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 thes 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:Cv Box 803100, Chicago, IL 60680-3100, ATTN: Disabled Permitting Section. A $25.00 maintenaqbe lee 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 oi4 i / i3i 5\0 2. State Identification Number £ 1 i 1T11iTlll c J£f Drivers Licepse Number ^12. Slo'feH'H. I7T1 ISI&io
4. Applicant Last Name Di^M/h i m i i i i iii Ml First Mame K'C6\lH)\ ri 1111
5. Home'Address (primary residence) &\rMYMl%7iMMZ\£il)\Mub\ i i i i i i i I£i3i£.k3|99|
6. Address where signs will be posted „ SIBEET NUMBER I DiR,| STREET NAME . 1 WARD NUMBER %7?\- i l l I l M il \0\W)
7. Phone.Numbers Home 1 7 17 i3T£i£d.#^ ¦ 1 Business 1.1 T 1 l- T 1 1 ¦ I !"
8. Current Permanent Disabled Placard Number . Registered to Relationship to Applicant '
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[9/Current License Plate Number f \ Reaistered to Citu Rfinkpr Nn P . .6o'.o 17^-8 Relationship lo Applicant
1D. Description ol Medical Condition and Disability - ...
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