APPLICATION FOR DISABLED PACKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING IHE FORM
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An application will nol be considered complete unless
All lines of the application have been compieledin full;
A check or money crdsr for S7C 00 made payable tc the City ot Chi.:ag< is submitted as.payment of the application fee; Please nole: The application fee shall be waived for any person hoiiling a valid, current disabled veterans plate'.
Disability must be permanent as evidenced by u copy of your valid t'isa. >led placara and/or current vehicle registration submitted al the time ot application:
Proof of residency, in the form of a copy of your drivE :s license, stat.' idf ntification, or utility bills are submitted at the time of application.
Completed application forms may be returned to: the offke of your aldennan any City of Chicago Department of Revenue facility, or via mail at P.O. Box 8031 DO. Chicago. IL 6068C-3100, ATTN; Cisal led Permitting Section A S25.00 maintenance fee will be billed to you annually. Should you have questions or concern:, pi >ase call our permit processing division at 312-744-PARK (7275).
1. Date of Birth
MO _ D/>.V
__YEAR
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O \£> 10 \3 \£ \b
2. State Identification Ni imber
4. Applicant Last Name
Ij. iic Audreys (primary resiCiencRj
SIBEET NUMBEP
1.1
3. Drivers License Number
f SipEriT NUMBEP DIR. STREET NAME \
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6. Address where signs will be posted
STREET NUMBER I r»« I STPS?tnamE
Phone Numbers Home
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8. Currant Permanent Disabled Placard Number
9. Current License Plate Number
I
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. WARD NUMBER
Business
Registered o
A Hrjgic crod to
Cit;' Stii ker NO.
Seisms
5T-
Relationship to Applicant
Relationship to Applicant
Alternative Parking. Please note your application may be deninri .'I you have alternati 'e a cessiMe cfl-stroet parking options.
11. t? there off-street parking available at your pr.mary residence (i.e garage, car port, driveway, etc )?
□ YES JS.NC
12. If you answered Yes to question 11, please describe. □ Garage; □ Driveway, □ Car Port; □ Other
13.1s your off-street parking accessible7
3.is y
Yes:
□ No. Please explain:
14. Affirmation: I hereby affirm that the above information is true an: correct. If the City c Chicago Department ol Revenue determines that the applicant has lalseiy represented one or more of the above iDnrjitions, the acplic; 11 sha I be subject to a fine ot not less than $100 but no more than $500, and the application sfiall be denied. I i- 'so understand 11 at it s my responsibility to notify rho Department ot Revenue ot any chanQES in the informal
Sicna'urc
rvy.
FOR OFFICE USf ONLY