APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
74246
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 ot 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 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 31?" 744-PARK (7275).
6. Address where signs will be posted
STREET NUMBER OIR STREET NAME
3 mil Nj|fcis>i*i ip Kmc
1. Date of Birth
MO _ OAY
o m oi5 15 la
2. State Identification Number
4. Applicant Last Name
H|g|H*|A |r>|T>l£ p.
3. Drivers License Number
^|S^i^i^|5pii^iiiMlf/^ fs \y \<i\i |6 is ipTinli'
First Name
5. Home Address (primary residence)
STREET NUMBER
_ .... STREET NAME
7. Phone Numbers
Home
in I3T5 1*8 \2TI \<o
8. Current Permanent Disabled Placard Number
9. Current License Plate Number
( 13
Business
5 1 \ P 1 3 | 3 i o i I |S 11
Registered to
Registered to
City Sticker_Nfl,.-
Relationship to Applicant
Relationship to Applicant
10. Description of Medical Condition and Disability
Attematrve 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 □ YES ^(nO (i.e., garage, car port, driveway, etc.)?
12. If you answered Yes to questi □ Garage; □ DrjvewSy:
please describe: □ Car Port; □ Other
13.1s your res
eet parking accessible? □ No. Please explain.
14. Affirmation: I hereby affirm that the above information is true and correct. If the City ol 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 fine ol not less than .$100 but no mare than $500. and the application shall be denied. I also understand that it is my responsibility to notify Ihe Department of Revenue of anf ihar^es^fTTha^formatlon p^vided
Signature
Date
FOR OFFICE USB. ONLY
PLACARD/PLATE
RESIDENCY
C i"K5-b tj. iit
□ COMPLETE ^-j,