APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
73484
7.
An application will not'be considered complete unless:
All lines of the application have been completed in full; :- '":
A check or money oraer for S70.00 made payable' to;the City of Chicago is submitted as payment of trie application fee; " Please' note: The appli'catfdhrfee-shall b'e'wa'iveti fbr;ahy persbn'hblding'"a:valid; ;eu '"Disability rriu's:t3'e'pe'rm^
submitted at .the time of application; ■'■'*'- ''■ ■;
Proof of residericy- in the fbrm W 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
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4. Applicant Last Name
2. State Identification Number1'
3. Drivers License Number
Ml
First Name
5. Home Address (primary residence)
' STREET NUMBER DIR.J STREETNAME
mi/irr \M ffitu \c\<*\o\
II ZIP.CODE
6. Address where signs will be posted
DIR. STREET NAME
STREET NUMBER DIR. STREETyAME
, WARD NUMBER
7. Phone Numbers
Home
Business
8. Current Permanent Disabled Placard Number
Registered to
Relationship to Applicant
9. Current License Plate' Number
Registered to ■■'
City'Sticker No. .■
Relationship to Applicant
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 ■(i.e., garage, car port, driveway, etc.)?
□ YES 4-MCf
12. If yoU answered Yes to question 11, please describe:
□ Garage: □Driveway; □ Car Port; □other:
13.1s your off-street parking accessible? i^L-Ye'sT □ No. Please explain:
"'14'. Affirmation: I hereby affirm that the above information is truo and correct: If the City o! Chicago'Dcoartmen: o! Revenue determines' ;that the'applicant has falsely represented one or more bf'tbe'above'coriditi'ons, the applicant shall-be subject to a fine of not less than '
■ $"100 but ho more than $500, and; the application1 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 .
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Date y; r///-
FOR OFFICE USEQKlLY
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PLACARD/PLATE
RESIDENCY
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February 23, 2011
ALDERMAN BERNARD STONE WARD 50
121 N LA SALLE STREET - 203 CHICAGO, IL 60602
Dear ALDERMAN STONE:
Please see the attached application for disabled parking signs. The applicant is requesting a restricted parking space within your ward.
The Department of Revenue will conduct a parking study and review the application for compliance with Chapter 9-64-50 of the Municipal Code of Chicago. The Department will make its recommendation to you within thirty (30) days of the receipt of the application fee.
Should you have any questions or require additional information, please contact our office at 312.742.7434.
Very truly yours,
-William Kenan Deputy Director Department of Revenue
Enclosure: Disabled Signs Application