A-> app.!catto»:
APPLICATION FOR DISABLED PARKING SiGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING-THE FORM
no? oe considered conirjfcJte'i/rifefjs:
Ail imes ol the application have been completed in full:'?5^''/^
74237 '
A check c! money eider for S70 00; made payable to.tfe'Gily of Chicago 15. su£n>ttert as p?ytntMit of t:v
j?iease noie: The application fee shall be'waived for any person-holding a valid, cufranrdisaofed veterans piale. */;/'f Di----.itiihiv must be permanent as evidenced fcy a copy of your w»Hcl disabled pi -.-art -id/o.- rurr.^t yp'm~ v-ytetritit-r T' suonrtitted at iha time? of application;- ^V-. - vx^-'b AciC' rv
v pio* i swhtency, ihe- lorrn uf a c:.ovci ycur diivars ^cense, stato idenliriivUiO?* ■:' s.a^; hilt::, arts i^rn-^sc?
Urn*:- of application. ' i j ' 11 ^
Completed application fcrrns may be returned to: hvj nflica of your alderman, any Cily ot Chicago Daoartmenr %>. Raw* tus-Eerily, tM v.'ii'ma'! *, P.C Bcv *03100. Chi:v*gc. IL OCSSO-SlOO. ATTN: Disfehifd P.?»n*.....-jf?cu;o'-., A . .iinl'-iarr-
fee win o<i biaed lo you annually. Should vou have question* cc concerns, please caii ue^/iit ptv.<:^$&>nQ oii- -'.".un : 3t£ v-,.!.pAaK ( r::?5!
S 2 Stats Ider-«ificaii3» Number j 3. Drive-? Uovse f^sbo
C 21
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_F:rst
5. Horru* Address {primary residence)
l1 i.JSi2l:XL...[!-rl J^_.;:.ii:u.JL!.^.^i
i 6. A{tdr«*s& wi^ic signs pa posted
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H'j'TIB
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i I : ^ , ■'. f ; j j 7 NUlTl(}!i!5
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i Business
______I
8. Current Permanent Otsatisad Placard Number
. Registered to
5 Currc''! License Plate Number
Rogistfiffiri to
i City Srirttef
Reiationshlo to Aoplicsrvt
"'i '<= /^v'sAl/l ■"' "'1/
IC.O^ -'-.fj'iori o» Medico' Condition and Ohao:liN*
Alternative Parking. Pidase note your applicahC!1 may be du^iod n you havo alternative Bccc;.»ibk» o!f-street par King Oj:: ms
t'.fe the:e off;ir«et paring available at your primary restdcr-ce ~i YES NO I (i.e., garago. car port, drweway etc.)?
1
I '.-il yoy 9r»w<f'ec» Van to c«K»stjon 11. piaasa t'escrwr
J Gatafle; :J Diivway; 'J Car Port; J Other:
13 (a yow off-sjraet parking accessible7 St i
T.
14. Affirmation: t hereby aitirm that the above.tritorrnaiion is true and correct. II the City of Chicago Department-ol Revenue determines that Ihe applicant has fafse-'y represented one cr mora of-(he above condilions, the applicant shall be subject to a fine of net fsss than S100 but no more than $500. and the application shall Pa denied. I also understand that it is my responsibility (o notify the Dt-partmirtt vi< Revenue of anyjr^pges in the^orrnjitrtjrl provided.
'. Sionaturo /T^r^^r^^^'.; ...................................__................ Dntc ^/M/ //
FOR OFFICE USE ONUY fy^ rt7~ft^ f" ' ■ j£l FEE
1
VPL
'^/PLACARD/PLATE" ^RESIDENCY □COMPLETE