49040! 1M7/05
APPLICATION FOR DISABLED PARKING SIGNS 76667 PUEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
An application will not be considered complete unless: ¦ All lines of the application haye been compjeted in full;
• A check or money order for $70.00 made payable to the City of Chicago is submitted as payment of the application fee; Please note: The application fee shall be waived for any person holding a valid, current disabled veterans plate;
• Disability must be permanent as evidenced by a copy of your valid disabled placard and/or current vehicle registration submitted at the time of application;
• Proof of residency, in the form of a copy of your drivers license, state identification, or utility bills are submitted at the time of application.
. Completed application forms may;be returned to: the office of your alderman, any City of Chicago Department of Revenue )\ijfy$mjfi or via mail at P.O;jBox 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
2. State Identification Number
3. Drivers License Number
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4. Applicant Last Name
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;s;/Home Address (primary residence)
g ZIP CODE
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WARD NUMBER
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Business
8. Current Permanent Disabled Placard Number
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Relationship to Applicant
9. Current License Plate Number
Registered to
City Sticker No.
Relationship is, Applicant
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Alternative Parking: Please note your application may be denied if you have altemative accessible off-street parking options.
Hon and Disability
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il , is triers off^ree^/parklng available at your primary residence $i%^^^t^^^^-^^Vf etc;)?
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