Mar 09 2011 4:17PM
HP LASERJET FRX
773-523-8440
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APPLICATION FOR DISABLED PARKING SIGNS PLEASE READ THE FOLLOWING CAREFULLY BEFORE COMPLETING THE FORM
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65031
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
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2. State Identification Number
3. Drivers License Number
4. Applicant La3t Name
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First Name
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5. Home Address (primary residence)
STREET NUMBER DIR. I STREET NAME
STREET NUMBER DIR. I STREET NAME , f ^ _
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6. Address where signs will be posted
STREET NUIKR OIR. | STREET NAME . Jl f |
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WARD NUMBER
7. Phone Numbers
Home
111 I3TI0I7-RT^I )
Business
B. Current Permanent Disabled Placard Number
Registered to Roy?.*- Bf^i-V-Vrrrx
Relationship to Applicant D* A_
9. Current License Plate Number
Registered to
City Sticker No.
Relationship to Applicant
10 Description of Medical Condition and Disability
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Alternative Parking: Please note your application may be denied if you riave 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 J5j NO
12. If you answered Yes to question 11, please describe:
□ Garage; □ Driveway; □ Car Port; □ Other:
13. Is your off-street parking accessible? □ Yes; £1 No Please explain: -^^-^ ri*-r v^»«v ^
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 ot not less than $100 but no more tnan $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.
Revenue of any changes in the information provided.
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Date
3-7-11
FOR OFFICE
E ONLY
□ FEE
□ PLACARD/PLATE
□ RESIDENCY
□ COMPLETE
Mar 09 2011 4:17PM HP LASERJET FAX
773-523-8440
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I I I I
I I I I
00058260
163098314
Healthcare Programs for Families
Case ID Number
96
202
22
DQ0066
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Eligibility Periods^^fe:-^>^^^^^^y^^:;!^;r:d
03-01-11
Through
03-31-11
CASELOAD:
902
BRITT0N, SARAH
3316 S WESTERN AVE # 1
CHICAGO. IL 60608-6005
No copays for children under age 19 or pregnant women. No cqpays for generic prescriptions, lab, radiology, emergency or family planning services. Adult copays are $2 for certain types of medical visits, up to $3 per day for certain types of Inpatient hospital stays and $3 for brand name prescriptions.
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Mar 09 2011 4:17PM HP LASERJET FAX
773-523-8440
REMOVE BEFORE VEHICLE IS IN MOTION. THIS PLACARD IS NOTTRANSFERABLE. IT IS ILLEGAL TO COPY OR DUPLICATE THIS PLACAHD.
THE AUThC R'2_£0 nOLOE*'. '.VJi'l fr,F/ pPF.Stt.T ANO VU f>? f:M7*f OR HOT I ML VCmOL .V lHh I IML THE f'^RKifv'.'i krVviLXOL?. ^'"-fL" DSHf-:^ b^L'O. UNAUTHORIZED L'^E- M^av R-TSUtJ irj r \\<r. S-: Sh'JiU(>'-
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PERMANENT