BEFORE COMPLETING THE FORM
PLEASE READ THE FOLLOWING CAREFULLY .
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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 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 312-744-PARK (7275).
1. Date of Birth MO _ DAY ' _ YEAR & I a I ol 7 I yi 7 2. State Identification Number I I III l III l I 3. Drivers License Number /3 | V| 5-| | r | 7\9\7\ C\3\P
4. Applicant Last Name /3|c/l^l^|/?|//|//| | | | | | | | | | Ml First Name /i/£|/r|A/|
5. Home Address (pri STREET NUMBER many DIR. r. residence) STREET NAME II ZIP C0DE fi\A \A\K\S\t\0\£\ | | | | | |'| | | | o?|P
6. Address where sig STREET NUMBER .-iri 7 la. | . WARD NUMBER 1 1 1 II II 1 1 1 1 PL?
7. Phone Numbers Home 71 7 13 Jri p 15-T ° Business 7| a | p-y| sr\PJ? \ 9 | P |8. Current Permanent Disabled Placard ...
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