Persons With Disabilities Certification For Plates Or Parking Placard Page 2
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1
2SIDE B
JESSE WHITE
(To be completed by applicant)
Secretary of State • State of Illinois
DIRECTIONS:
Both sides of this document must be signed and completed in its entirety in order for the application to be
processed. Complete Part 1, if the person with disabilities is applying for plates and/or placard. Complete Parts 1 and 2, if the
parent, immediate family member or legal guardian of the person with disabilities is applying for license plates.
PART 1. PERSON WITH DISABILITIES
I hereby apply for:
____
Person with Disabilities Parking Placard
____
Person with Disabilities License Plates (Application and fee for registration must accompany this
form. Fee is based upon the current plate expiration, date of purchase of vehicle if newly acquired
or the date of application, whichever is applicable.) MUST HAVE A PERMANENT DISABILITY TO
OBTAIN PLATES.
under the statutory provision, (625 ILCS 5/1-159.1) and certify that my physical condition entitles me to the
issuance thereof. I am also aware that the person with disabilities parking device (whether plates or parking
placard) must not be used unless I am the driver or passenger in the vehicle.
_______________________
_________________________________________
Date
Applicant's Signature
WARNING: MISUSE OF OR FALSE APPLICATION FOR THE PERSON WITH DISABILITIES PARKING DEVICE can result in its
revocation, a 30-day driver's license suspension, and a fine up to $1,000. The person with disabilities must exit or enter the
vehicle when parking in areas reserved for such person or when parking at metered spots.
PLEASE PRINT OR TYPE BELOW:
Name of Individual with Disability
Date of Birth (Month/Day/Year)
_______ OR _______
Male
Female
Address
City
ZIP
Driver's License # OR State ID Card Number of Individual with Disability
Telephone
(
)
PART 2. DISABILITY LICENSE PLATES FOR PARENT, IMMEDIATE FAMILY MEMBER OR LEGAL
GUARDIAN ONLY:
I hereby apply for disability license plates as the parent or legal guardian of the individual with a disability. The above
named person with disabilities, owns no vehicles and relies frequently on me for his/her mode of transportation.
Parent's Name, Legal Guardian's Name OR Family Member's Name
Date
Address
City
ZIP
Telephone Number
Relationship to Disabled Person
(
)
FOR OFFICE USE ONLY
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Placard number_____________________Exp._________Issued by___________________Date______________
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