APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
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 she appl^a: on 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 st Ihe time of application; ■' .r ■■ ' ■ ■
♦ Proof of residency, in the form of a' copy of your drivers license, state identification, or utility bills are submitted ;u 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 b.iled to you annually. Should you have questions or-concerns, please call our permit orocessfng dMsiori at 312-?<14-PARK .-7J75) j'■ '
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State Identification Numhdr
! 3. Drivors License Number
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p:. Applicant Last Name rr" ■-■
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Firs; Name
5. Home Address (primary.residence).
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I 6. Address where signs will be postal!
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7. Phone Numbers
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8. Current Pernmr.eni Disabled Placurt! Nurobt
9. Current License Plate Number
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Business
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Registered to
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City Sticker No.
Rcir>i-on£hip to Arip'■■jilt
Relationship to Applicant
!0. Description of Medical Condition arid Disability
Alternatives Parking: Please note your application may be denied it you have alternative accessible off-street parking opticus
11, Is there off-strost parking available at your primary residence □ YES □KNO <i:e garags, car port, driveway, etc.)? _
*2 Ii you answered Yes to question 11, please describe: □ Garage: 'J Driveway: □Car Port 'J Other;
13. Is your off-slreet parking accessible? □ Yes: □ No. Pioaoe explain:
14. Affirmation: I hereby affirm that the abovs information is true and correct. If the City of Chicago Department of Revenue determinas that the applicant has falsely represented one or more of the above conditions, the applicant shell bo subject to a tine 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 Oepanmsnt-cf:. Revenue of any changes in the information provided.
Signature
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Date.
FOR OFFICE USE ONLY
AFEE
PLACARD/PLATE J&KESIDENCY
□ COMPLETE % -1