APPLKJAMUN hUH DISABLED KAttMNU OIValNO PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
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An application will not be considered complete unless:
• All lines of the application have been completed in full;
A check or money order fc S70.00 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).
Date of Birth
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2. Stale Ideniilicahon Number
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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 I CMR | STREET NAME
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IZIP CODE b\0 |6ijnef
6 Address where signs will be posted
STREET NUMBER I DIH J STREET pJAME
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WARD NUMBER
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7. Phone Numbers Home
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8. Current Permanent Disabled Placard Number
Registered to
Relationship to Applicant
9. Current License Plate Number
Registered to
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City Slicker No.
Relationship to Applicant
10 Description of Medical Condition and Disability
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ay be denied if you have alternative accessible off-street patting options. /
Alternative Parking: Please note your application may be denied if you have alternative accessible off-street patting options.
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ii. Is there off-sireet parking available at your primary residence {i.e., garage, car port, driveway, etc.)?
12 If you answeied Yes to question n, please describe:
□ Garage: □ Driveway; □ Car Port; □ Other
13. Is your oH-sireei parking accessible? □ Yes; □ No. Please explain:
14 Affirmation- I hereby affirm that the above information is itue and correct. II ihe City ol Chicago Department of Revenue determines that the applicant has falsely represented one or more of ihe 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 ot Revenue of any changes m ihe information provided.
Signature
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FOR OFFICE USE ONLY
□ FEE
J PLACARD/PLATE □ RESIDENCY
□ COMPLETE
tsablcd Parking Application Payment Stub
'lease make check or money order payable to the City ot Chicago r
/hen paying with a credit card, please fill in the following information.
HiS PAYMENT WILL HOI BE PROCESSED IF MOT SIGNED
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Exp. ^ <> . Date I*-1! "I
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1 signing nert I agree id lot terms ana conditions oTiftii njtice
PLEASE
• 00 HOT lend cult
• 00 NOT fold ihe pjjmtnr itub(j)
• 00 HOI staple Ine check a monct a ptTintni iiuoli)
TOTAL AMOUNT DUE
70.00
PAYMENT AMOUNT ENCLOSED
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