APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
74131
An application will not be considered complete unless:
Ā All lines of the application have been completed in full;
Ā 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.
Ā 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;
Ā 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
3
2. State Identification Number
3. Drivers License Number
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4. Applicant Last Name
t~i EismAi
Ml
First Name
Ml I i\)iO
5. Home Address (primary residence)
STREET NUMBER DIR. STREET NAME
3I2JM9I N
OlSlAlGlEl I Al Vi &
6|0 |fe |S
6. Address where signs will be posted
STREET NUMBER DIR. STREET NAME
, WARD NUMBER
3IZI (191 H 0|S|A-|Ā£|Ā£"i IA-i VfF
7. Phone Numbers
Home
Business
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8. Current Permanent Disabled Placard Number
7
Registered to K) I kJO ~VC$TA
Relationship to Applicant
9. Current License Plate Number
F31 ^b37
Registered to
M ^OT^^rA
City Sticker No. ?
Relationship to Applicant
10. Description of Medical Condition and Disability
L Ā£ FT ue & A M P'O TA T7 O M
Be LOW KMtĀ£
3 Ti^EST
O/ALV^L p.4TTĀ£M~T
Alternative Parking: Please note your application may be denied if you have alternative accessible off-street parking options.
11. Is there off-street parking available at your primary residence 3 YES □ NO
(i.e., garage, car port, driveway, etc.)?_^'AMMOT OS ^Ā£ T^cA\J$Ā£ jr \)<,'E UMgĀ£L- Cf-Mifc,
12. If you answered Yes to question 11, please describe:
5^Garage; □ Driveway; □ Car Port; □ Other:
13.1s your off-street parking accessible? □ Yes; J3.No. Please explain:
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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
0
FOR OFFICE USE ONLY
□ FEE □ PLACARD/PLATE □ RESIDENCY □ COMPLETE
r
Cily of Chicago
The Department of Water Management
P.O. Box 6330
Chicago, Illinois 60680-6330
NON-METERED ACCOUNT
To save money and water, call 3-1-1 or go to www.rn_etgrsave.orq for your FREE water meter. HOTLINE: Water in your street or basement? Always call 311. Never e-mail.
PAY ONLINE: Pay your bill online from the convenience of your home or office. See back for details\_t--/
NINO-TESTA
405238-405238
Jul-29-2010
Aug-19-2010
Service Address:532T9 N OSAGE'AVE;CHICAGO. IL 60634-2950
Summary of Charges for May-01 -2010 thru Oct-31 -2010
Total Current Water..................................................................................... $ 104.05
Total Current Sewer.................................................................................. $ 0.00
Penalty....................................................................................................... $ 0.00
Total Current Charges.........................................,............................... $ 104.05
Previous Balance....................................................................................... S 99.81
Adjustments.......................................................................,....................... $ 0.00
Payments................................................................................................... $ 99:84-^
Total Due.................................................,.......................................,...... S /f04^>S~~>,.
Ls<te payments are subject to penalty.
The Department of Revenue's Water Division offer? a variety of flexible payment plans for water bills including a special cjrcumatances/hardshlp plan for those who qualify. Avoid Woter shut oft or have your service restored by entering a plan. Visit us on-line or call us for mcirelnformatlon.
Assessment Details
! FLRS 24' WIDE BLOC (000 S) HOSe FRONTAGE V ■:<<;,"
TO.98 26.07
DfinSDID DDDM0S23flDLl0Sr23a b □□D0D1D4QS DDDDD1DM0S 7
REMOVE BEFORE VEHICLE IS IN MOTION. '
^ THIĀ§ PLACARD IS NONTRANSFERABLE.-IT ISILLEGALTO COPY OR DUPLICATE THIS PLACARD.
HE AUTHORIZED HOLDER MUST BE PRESENXAND MUST ENTER OR EXIT HE VEHICLE AT THE TIME THE PARKING PRIVILEGES ARE BEING USED. INAUTHORIZED USE MAY RESULT IN A S500 PINE AND/SUSPENSION OF 1 IRIVER S LICENSE AND/OR REVOCATION OF.THE PLACARD.