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
MO _ _ DAY
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2. State Identification Number
3. Drivers License Number
D
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4. Applicant Last Name
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First Name
6k imDiA!
5. Home Address (primary residence)
STREET NUMBER DIR. STREETJ^AME
l\<\Wf\\ V\ WirSlwlLlAl/oiD
I ZIP CODE
lUlO IU 13 W
6. Address where signs will be posted
STREET NUMBER DIR. STREET NAME
, WARD NUMBER
'1
7. Phone Numbers Home
Business
1 I b
8. Current Permanent Disabled Placard Number
Registered to
Relationship to Applicant
9. Current License Plate Number
Registered to
City Sticker No.
\5 xvtiM
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-street parking options.
11. Is there off-street parking available at your primary residence (i.e., garage, car port, driveway, etc.)?
YES □ NO
12. If you answered Yes to question 11, please describe:
CmBarage: □ Driveway; □ Car Port; □ Other:
-^-.--,-_
13. Is your off-streetoarking accessible? h>i/%c<uJJ u/sU.tiit -froryy -frti/J- di hdn^L TO tfd'*^ ('^^ EfNo. Please explain: L _ . \ ' *°
□ Yes;
7
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 the 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.
Signature
Date
1-
FOR OFFICE USE ONLY
□ FEE □ PLACARD/PLATE □ RESIDENCY □ COMPLETE
Jesse White - Secietaiyo! Stale
l;.3UKD _EXPIRES
07-16-03
GILDA DE CICCO 2929 N NEW LAND AVE CHICAGO IL.60634
os ?rui7B DRIVERS LICENSE
Birthdate 08-2CK36
Female '5'OT 130 lbs BLUE Eyes
Restrictions Type Class
B ORG D