Mar
2011 9:53PM
HP LASERJET FAX
773-523-8440
APPUCATION FOR DISABLED PARKING SIGNS 75225 PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
An application will not be considered complete unless: Jk
All lines ot the application have been completed in full; IQJ W\
A check or money order for $70.p0 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 submilted 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 _ nur
2. State Identification Number
11
3. Drivers License Number
A\2\?.\3iS\s\q\Sr3\l K?f7
4 Applicant Last Name
Aoin!.si4ia
Ml
First Name
5. Home Address (primary residence)
STREET NUMBER j P1W I STREET NAME l
MlUiq-13 1 ISlEln ic lid cull ll 1 \
ZIP toot
b\0\U\5\Z
6. Address where signs will be posted
STREET NUMBER I DIR. I STREET NAME .
4lGiai3l ISlffihICIfr.ltvlllI
I I I 1112
WAPD NUMBER
7. Phone Numbers
Home
Business
Q i iFraisiiTSH pig
6. Current Permanent Disabled Placard Number
Registered to
Relationship to Applicant
9. Current License Plate Number
Registered to
City Sticker No.
Relationship to Applicant
10. Description of Medical Condition and Disability.
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 Catoo
12. If you answered Yes to question 11, please describe:
□ Garage; □ Driveway; □ Car Port; □ Other:
13. Is your olf-street parking accessible?
□ Yes; %No. Please explain:'fV^ )S (\ A CNPjtCjfDj>A\lV\ Cjr MOhiQ^S OA V^X.U
Jim
atv of-et-
14. Affirmation: I hereby affirm that the above information is true and correct. It the City Af-chicago Department ol Revenue determines that the applicant has falsely 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 Ihe application shall be denied. I also understand that it is my responsibility to notify Ihe Department of Revenue of any changes in tne information provided.
Signature.
Date
FOR OFFICE USE ONLY
□ FEE □ PLACARD/PLATE □ RESIDENCY □ COMPLETE
Mar 03 2011 9:53PM HP LASERJET FHX
773-523-8440
p.2
rVKv^iS^FdRfe VEHICLE IS iN MOTION. : THIS PLACARD IS KfOTTRANSFERABLE. ft IS iLLeoALTO COPY OR DUPLICATE THIS PLACARD.
'Hp' AUTHORED HOLt3r;P 5/IUST BE PPESEHT ADD K1UST ENTER OR EXIT ■HE' VEHI'r'i.G ATtHE TiME THE PAHKtNQ PRIVILEGES ARE SEIN'o USEt). 5tth>1 WfttZEfc URfe WAV RE3ULT W A OSO'i FINE AMD SUSPENSION Of )RIW£n-sLlCENSE AWD.'OPREVCCAriONOFlHf; PLACARD: .
PERMANENT
BB 56038
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