application for disabled parking signs please read the following carefully Before completing the form
77410
Arrap^caTion will not bte fiAhgidered complete unless:
• All lines of the applicam^ri have been completed in full;
• A check or money onjrer 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 _ YEAR 0 lS I 2- [M I 1 (S 2. State Identification Number 3. Drivers License Number p| 1 Kb lib 1 d b 1 s lt> |e> \(o
4. Applicant Last Name \ 1 Pi alU \ lo 1 1 1 1 1 1 1 1 1 1 1 Ml First Name &i 1 5) b 1 T | "i e 1 1 1
5. Home Address (pri STREET NUMBER 2 11 IS k 1 mary DIR. V residence) STREET NAME II ?lp CODE NMrlal Kkkl^ldvl 1 1 1 1 1 1 kl^lU^la
6. Address where sig STREET NUMBER 2-J 1 IsJ H 1 ns w DIR. II be posted STREET NAME IH l?Jr IcA 1 IS Mr WARD NUMBER e. \? Kl- 1 1 1 1 1 1 1 1 II 1 1
7. Phone Numbers Home 1 1 1 b 1 5 1 2 1 ^ 1 1 H ...
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