APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
73480
\n 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. 7* 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; L7» 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 $25.00 maintenance fee will be billed to you annually, Should you have questions cr concerns, please call our permit processing division at 312-744-PARK (7275).
1. Date of Birth
MO _ DAY
0 I 7-
YEAR
41G
2. State Identification Number
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3. Drivers License Number
51/ \6\z \6\/g \y
Ml First Name
4. Applicant Last Name
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K\B\i<l\ff\L
5. Home Address (primary residence)
STREET NUMBER DIR. STREET NAME
ZIP CODE
6 \g [5-161 I IM\±\e\£\L i^ iy 1 \/f~\y I \A> t 13 |S| i \e\o$ fr^-
R AHHrocc iMhoro cinnc i A/r 11 h,o nnetaH '
6. Address where signs will be posted
STREET NUMBER
STREET NAME
, WARD NUMBER
7. Phone Numbers
Home
Business
"7
✓
•i 7
8. Current Permanent Disabled Placard Number
fc fe H1Q57
Registered to
Relationship to Applicant
V- R(
9. Current License Plate Number
4 GG /
Registered to
City Sticker No.
Relationship to Applicant
"Kijana Sefe
n7^M3/ L'ncoln Ave ^77j
? rnW^ typical Center
A ■
Cc7
r°Wc,. M.6
ivo N Lincoln Ave iiicago, IL 60625
-'-7"-~—1-/-— UfllCabn II cng—~^-1' J ^07 8255—
Alternative Parking: Please note your applicatfon may-be denied'if you have aferattve'acBesQiBS off-street parking options
Tl. Is there off-street parking available at your primary-residence Bf^ES □ NO
(i.e., garage, car port, driveway, etc.)?
12. If you answered Yes to question 11, please describe:
□ Garage; ©^Driveway; □ Car Port; □ Other:
13.1s your off-street parking accessible? SfYes; □ No. Please explain:
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
FOR OFFICE USE ONLY
□ FEE □ PLACARD/PLATE □ RESIDENCY □ COMPLETE
Jesse White - Secretary of State
04-2Z-O9
NUMBER ' ISSJED
SI62-5004-6120 09-1.5-04
KEMAL SEFERAC5IC 6656 N SEELEY-AVE CHICAGO IL 60645 .
SSr-S^Sb,' BLUE Eyes Restrictions Type Class.
ORG • D
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