Mar 08 2011 4:19PM HP LASERJET FAX 773-523-8440
APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
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75225-
An application will not be considered complete unless:
AM 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 fee Please note: The application tee 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 Ihe 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 ol Birth
MO _ DAY _ YEAH
O 13 I 3. I 7 I k 13>
2. State Identification Number
IL
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3. Drivers License Number
vi*lolaT-7l 31 Si CLMaUh
4. Applicant Last Name
XKIalol I I I I I I
First Name
5. Home Address (primary residence)
STREET MUMBER
UI ah b I s
IMBER 0B. j STREET MAME II 7/P CODE
bl IskkUlplftk 11 Ml lANkl M I i I I UloHPia
Address where signs will be posted
STREET NUMBER I DIR. STREET NAME
I I I I M < 1 I
WARD NUMBER
7. Phone Numbers
Home
Business
8. Current Permanent Oisabled Placard Number |
Registered to |
Relationship to Applicant |
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9. Current License Plate Number 5~7<i37 r P |
Registered to |
City Sticker No. |
Relationship to Applicant |
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10 Description of Medical Condition and Disability Wfl S ', a cow Ace
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 (i.e., garage, car port, driveway, etc.)?
□ YES &QiO
12 If you answered Yes to question 11, please describe:
□ Garage; □ Driveway; □ Car Port; □ Other:
13. Is your off-street parking accessible?
QYes; QLHo. Please explain: -VVxcr c aye, ^ \flT ^ Cw S -VUcTT ^UA y k ]vi"Hc
14. Affirmation: I hereby affirm that the above information is true and correct. If the City of Chicago Department of Revenue determines that the applicant has falsely represented one or more of the above conditions, the applicant shall be subject to a line 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 Ihe Department of Revenue of any changes in the information provided.
Signature.*^
Date.
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FOR OFFICE USE ONLY
□ FEE
□ PLACARD/PLATE
□ RESIDENCY
LI COMPLETE
Mar 08
2011 4:19PM HP LASERJET
FRX
_ ^ tHfe PLACARD IS NQTTRANSPEflABLE.
rf is Illegal Td copy or duplicate this placard.
773-523-8440
"HE AUrHdRIZED'flCLbFh MUST HE me.Sr'JT AND MUST ENTER Oh fx IT HE VEHICLE AT THE TlttE 1H6 PARKMG PDH'ILCGES ARE BEING USED NAUTHpmZEtf USE. MaV HEbUlt IN a SbCO RME AND SUSPENSION D= RlVEfl S LICENSEAHD,'OR fcEVOCA^Oh OFTHE! f»l-.A.i;f\RD.
PERMANENT
BB 28494
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NUMBER ISSUED
V200-■/:}.%■ 3089 02-2OO8
RUPERTO VVfHGA 40S3 S CAMPBfiU. AVE CHICAGO IL 60633
Jesse White Secretary of State
Birthdate 03-27-63
Male 5'06" 2l0lt>s BRN Eyes
Re9t*9ions Type Clasfe
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