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Record #: O2011-961   
Type: Ordinance Status: Passed
Intro date: 2/9/2011 Current Controlling Legislative Body: Committee on Traffic Control and Safety
Final action: 5/4/2011
Title: Handicapped Parking Permit No. 73481
Sponsors: Stone, Bernard
Topic: PARKING - Handicapped
Attachments: 1. O2011-961.pdf
Related files: SO2011-4258
 
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
73481
An application will not be considered complete unless: All lines of the application have been completed in full;'
• A check or money order for S70.00 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).
2. State Identification Number
3.   Drivers License Number
4. Applicant Last Name                                                                   | Ml
First Name
5. Home Address (pri
mary residence)
6. Address where sig
ns will be posted                                                                                                           Â„ waho number
7. Phone Numbers Home
2 K
Business
8. Current Permanent Disabled Placard Number
Registered to
Relationship to Applicant
 
 
 
9. Current License Plate Number
Registered to
City Sticker No.
Relationship to Applicant Or i~ F
 
 
 
 
10. Description of Medical Condition and Disability    c ■ ~   -           .-»/».,.,-       ,•...  Â»                     ^    _ .
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        jHf YES    Si NO (i.e., garage, car port, driveway, etc.)?
12.lt you answered Yes to question 11, please describe:
□ Garage;    □ Driveway;      □ Car Port;       □ Other:
13.1s your oH-street parking accessible? Yes;        □ No. Please explain:
14. Affirmation: I hereby affirm that the above information is true and correct. If the City of Chicago Department ol Revenue determines that the applicant has lalsely 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   C£/0// 2. QU
FOR OFFICE USE ONLY
□ FEE
□ PLACARD/PLATE      □ RESIDENCY
□ COMPLETE
Disabled Parking Application Payment Stub
Please make check or money order payable to the City of Chicago or
when paying with a credit card, please fill in the following information.
THIS PAYMENT WILL NOT BE PROCESSED IF NOT SIGNED
Card No.
4
3
 
8
57
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O
4
2
1
7
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Z
O
3
Date 1/
Signature:.
 
PLEASE:
> 00 NOT send cash
■ 00 NOT laid the payment Etub(s)
■ 00 NOT staple the check or money order to the payment stub(s)
By signing here I agree to tha tints and conditions oi this notice.
TOTAL AMOUNT DUE
70.00
PAYMENT AMOUNT ENCLOSED
$   70. ot
10 ENSURE PROPER CREDIT PI EASE RETURN THIS STUB WITH YOUR PAYMENI
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