APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
74131
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 t(3;Jhe office of your alderman,.iany City of Chicago Department of Revenue facility, or via mail at P.O. Box 803100, Chicago, IL 60680~-31007 ATTN: Disabled Permitting Section. A $25.00 maintenance fee will be billed to you annually. Should you have questions or concerns, please call our permit processing division at 312-744-PARK (7275).
1. Date of Birth
MO__DAY
Oil I D I
I I 3|1010|2. State Identification Number
3. Drivers License Number
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4. Applicant Last Name
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First Name
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5. Home Address (primary residence)
STREET NUMBER DIR. STREET NAME
3I2JM9I N
OlSlAlGlEl I Al Vi &|100 |fe |S
6. Address where signs will be posted
STREET NUMBER DIR. STREET NAME
, WARD NUMBER
3IZI (191 H 0|S|A-|£|£"i IA-i VfF
7. Phone Numbers
Home
Business
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8. Current Permanent Disabled Placard Number|1010|Registered to K) I kJO ~VC$TA
Relationship to Applicant
9. Current License Plate Number
F31 ^b37
Registered to
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City Sticker No. ?
Relationship to Applicant
10. Description of Medical Condition and Disability
L £ FT ue & A M P'O TA T7 O M
Be LOW KMt£
3 Ti^EST
O/ALV^L p.4TT£M~T
Alternative Parking: Please note your...
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