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PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
T4482
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 O | z. | O | 3 I | I 2. State Identification Number OHJ3HTc| 0|34iTcj3l4P 3. Drivers License Number
4. Applicant Last Name p|ol9M/k!^l I I I I I I I I I Ml First Name Cjf4|fr |R| L|o|*|-/-|e| | |
5. Home Address (pri . STREET NUMBER mary DIR. 5 residence) STREET NAME : II ZIP CODE <£>! \R\o\s\T\AAe-\R\
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6. Address where sig . STREET NUMBER ns w ? II be posted STREET NAME; / . Ok \A\0\S\"ft/U\7. Phone Numbers Home 7 |7 \3T5~\g Z I 1 Business
8. Current Permanent Disabled Placar...
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