Mar 03 2011 8:52PM Feb 17 2011 6:09PM
HP LASERJET FAX HP LASERJET FAX
773-523-8440 773-523-8440
P- 1 P-3
£PPLtCATJ0N FOR DISABLED PARKING SIGNS 7740 PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
An application will not be considered complete unless: V" ~^4"^
Alt lines of the application have been completed in full;
A check or money order for 370.QO made payable to the City of Chicago resubmitted] as payment ot the application fee; Please note: The application tee shall be waived for any person fralding a valid, current disabled veterans plate
Disability must be permanent as evidenced fay 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 oopy of your drivers license, state identification, or utility bills are submitted at the time of application.
Compteted application forms may be returned tc; the office of your alderman, any City of Chicago Department of Revenue facilty, o; via mail at P.O. Box 1303100, Chicago. «. SD680-3100, ATTN. Disabled Permitting Section. A $25.00 maintenance fee wiH be bSled to you annually. Should you have questions or concerns, please call our permit processing division al 312-744-PARK{727S).
1- rJateofeirth I 2, State tcfentification Numb«r NO _ OAV _ y£A« O-l i I \ la I jy\ I H*lDi KilSKMfelriai |
K |
3. Drivers License iMumber k\) ioloTo ! \\a \sT'A \ l\ i la |
4. Applicant Last Name Rlulfcl HOJ I I ! I I ! I I I I I |
Ml |
First Name riimi/liiOiONM i I I i i |
S. Home Address (primary srneeTNUMBEH | dip. am )L5i w |
residence) STHECT HAkne 1 SP CODE 3181 lPiU/JlcUl 1 1 1 i 1 1 ! 1 ! 1 Ul*|fck3fl |
|
|
|
|
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6. Address where signs will be posted &rPSTN«;MBER an. street w»we
.ai7U 161
3)8\ U> u \n\c\£\
I t i I |OQ 12
7. Phone Numbers
7 I 7 ) 5 T
Home
Business
*i m? i 7 id
3. Current Permanent Disabled Placard Number
8 P
Registered to
1 I. L
Relationship lo Applicant
9. Current License Plate Number
Registered to _fS-U,b>P
City Sticker No.
Relationship to Applicant
10. Description of Medical Condition and Disability
Alternative Par King. Please note your application may be denied if you have alternative accessible off-street parking options.
11. Is there off-strew parking available at your primary residence (I.e., garage, car port, driveway. etc.)7
□ no
12. If you an&wered Yes to question 11, please describe:
□ Garage; ffi.Prtvewsy; Q Car Port; Q Other:
13. Is your ofl-street parking accessible? i" 5 CracYerA v\iCr»<L^y Q Yea; %Mo. Please explaJn. Z ^ Vo ^Oar ft^p ) i.iAy my j< *<3 fCo ; Vt^lfwrA^t
14. Affirmation: I hereby afflrrn that the atove fntcrmalion is true and correct. If trie City of Chicago Department of Revenue determines, lhat the applicant has falsely represented one nr more of the above conditions, the applicant shall be subject tc a line at nol less than $100 but no more than $500, and Ihe application shell be denied. I also understand 1hat it is rny responsibility to notify t^e Department of Revenue of any changes in the Information provided.
Signature
Date TfVAo _._^iL
FOR OFFICE USE ONLY
□ FEE
□ PLACARD/PLATE □ RESIDENCY
□ COMPLETE
Mar 03 2011 8:52PM HP LASERJET FRX
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