APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
77751
An application will not be considered complete unless:
All lines of the application have been completed in full;
A check or money order for $70.00 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 al the time of application;
" Proof of residency, in the form of a copy of your drivers license, state identification, or utility bills are submitted a; ihe
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 billedto you annually.- Should you have questions or concerns; please call our permit processing division at 312-744-PARK (7275).
i. Daie or dirth MO _ DAY _ YEAR nil I \ I r\ I -7 I Q. |
2. State Identification Number 5!z|o|oTWe|2-BTo| 11 of <- |
3. Dnvers License Number - ! ~t-| T !-T 1 T I T ! |
4. Applicant Last Name M \k\0 O I I I I I I I I I I I |
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First Name AlUPl HolMlsl ulSI 1 1 |
5. Home Address (pr STREET NUMBER |
mary DIR. w |
residence) STREET NAME II ZIP CODE MH|Tlhl IS IT |R t'if 1 1 1 1 1 1 1 \(o 10 g $ |
6. Address where sig STREET NUMBER |
ns w DIR |
II be posted STREET NAME |
|, WARD NUMBER Ml......1 \lfh |
7. Phone Numbers Home "7 1"? |3 T^llo D T SIC* |
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Business |
8. Current Permanent Disabled Placard Number |
Registered to |
Relationship to Applicant Self- |
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9. Current License Plate Number |
Registered to |
City Sticker No. (V) Gj0<Z |
Relationship to Applicant vO c so e |
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10. Description of Medical Condition and Disability UfNiL\P>\<? "TO uoc>-LX |
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 □'YES □ NO (i.e., garage, car port,.driveway, etc.)? . ' <r |
12. If you answered Yes to question 11, please describe: fPftGarage: □ Driveway; □ Car Port; □ Other: |
13.1s your off-street parking accessible? □'res; .□ No. Please explain: |
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14. Affirmation: I hereby affirm that the above information is true and correct. If the City of Chicago Department of Revenue determines that the applicant has falsely represented one or more of tine above conditions, the applicant shall be subject to a fine 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 Department of Revenue of any changes in the information provided.
XiA0^*;_ Date £ ' / ^ )/■_
Signature
FOR OFFICE USE^ONLY
PLACARD/PLATE
RESIDENCY
□ COMPLETE £.-]0-