490-002 12/27/05
APPLICATION FOR DISABLED PARKING SIGNS 78053 PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
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
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2. State Identification Number|10£M T \h\o\
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3. Drivers License Number
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4. Applicant Last Name
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First Name
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5. Home Address (primary residence)
STREET NUMBER DIR. STREETJ^AME
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I ZIP CODE
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6. Address where signs will be posted
STREET NUMBER DIR. STREET NAME
, WARD NUMBER
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7. Phone Numbers Home
Business
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8. Current Permanent Disabled Placard Number
Registered to
Relationship to Applicant
9. Current License Plate Number
Registered to
City Sticker No.
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Relationship to Applicant
10. Description of Medical Condition and Disability
Alternative Parking: Please note your application may be denied if you have alternative accessible off-st...
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