APPLICATION FOR DISABLED PARKING SIGNS 74578 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 _ YEAR / la I o\ l |
2. State Identification Number L^I7Til^HT3|l|J |
3. Drivers License Number 6\ip\snjip\ix>\o\^\e>f\\H\x |
4. Applicant Last Name 6\ft\0\U)\rl\£\L\L\ | | | | | | | | |
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First Name f\/f\U.\L\T\ri\^\ | | | | |
5. Home Address (primary residence) STREET NUMBER I DIR. I STREET NAME ( 1 . _ || ZIP CODE 4|fe|4lk| lN|L|E|aifVl|r|AJ|f>|T|<9|/\l| IfrlVltrl 1 1 1 1 \tc\0\U>\5\o |
6. Address where signs will be posted WARD NUMBER STREET NUMBER 1 DIB. 1 STREET NAME \ 1 / y II . _ 4i&>wifoi WlLi^iAimiX|Ai^in^i/0| ifti\fi£r| i i i i i i 1 iv±5 |
7. Phone Numbers Home 1 n 13 T5l4 I5T^IA |
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Business |
8. Current Permanent Disabled Placard Number SF y ?.5£ 7 |
Registered to |
Relationship to Applicant |
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9. Current License Plate Number |
Registered to |
City Sticker No. |
Relationship to Applicant |
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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 5/YES Q NO (i.e., garage, car port, driveway, etc.)? fi{Z/OT^K £-A&l6r£ UAS/rXl/AZ2rf&-£' |
12. If you answered Yes to question 11, please describe: i. / -SttSarage; □ Driveway; □ Car Port; □ Other: |
13.1s your off-street parking accessible? jSc^es; □ 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
3L- 18-I I
FOR OFFICE USE ONLY
□ FEE □ PLACARD/PLATE □ RESIDENCY □ COMPLETE
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PAULINE BROWNELL -
4646 N LEAMINGTON AVE CHICAGO IL 60630-3813
Registration ID: 5713 7310 PIN: 3659
2012 Illinois Registration Identification Card Jesse White, Illinois Secretary of State
CNVE02/17/11:01:6192: hiti.00 CA W-MIDGE4 2CVE16192 m 0312
Vehicle Yrar 2001
Weight or CC's 08000
Axles
Vehicle Maltfi 0HR_YSI...EU Body Slylfi >;/l:A'f TRUCK v'fl/J
Leased/Rental
Unit Number
Drivftr's License Mnml.if;i'(nl or 1-1: IN(s)
B654-6604-B042
Renewal Fee Due j
106.00
3C8FY4BB31T317704
Application Type PERSON WITH DISABILITIES
File Number
County COOK
103
Expiration Dale MARCH 31,2012
Plate Number W-MIDGE4
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