Application For Replacement Disability Parking Placard Form - Illinois Secretary Of State

Download a blank fillable Application For Replacement Disability Parking Placard Form - Illinois Secretary Of State in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Application For Replacement Disability Parking Placard Form - Illinois Secretary Of State with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Reset

Save

pplication for Replacement

This space for use by

Secretary of State.

Disability Parking Placard

Secretary of State

Vehicle Services Department

When replacing a permanent disability

Special Plates Division

parking placard, submit all documentation

501 S. Second St., Rm. 541

and fees to the Springfield office.

Springfield, IL 62756

If mailing, use the address at left.

Name of Person with Disability _________________________________________________________________

Address ______________________________________ City/State/ZIP __________________________________

Telephone _____________________________________ Date of Birth __________________________________

Please check applicable box(s):

$10 Replacement Fee due to:

Lost

Damaged/Mutilated

Stolen — Attach Police Report

Non-Receipt

Circuit Breaker (No fee for qualified applicants.)

___________________________

_________________________________________________

Date

Applicant’s Signature

WARNING: MISUSE OF OR FALSE APPLICATION FOR A PERSONS WITH DISABILITIES PARKING PLACARD can result in its revocation, a 30-day driver’s license

suspension, and a fine of up to $1,000. The person with disabilities must exit or enter the vehicle when parking in reserved spaces or when parking at

metered spots.

If your name and/or address is different than when you last received your parking placard, please indicate

your previous name and/or address below.

Name _____________________________________________________________________________________

Address_______________________________________ City/State/ZIP _________________________________

FOR OFFICE USE ONLY

(must be completed by facility)

Current Placard # (if not shown above) _________________________ Issued By _________________________

Operator ID# and initials

New Placard # ____________________________________________ Issue Date ________________________

Expiration Date____________________________________________ Facility Name ______________________

If for replacement, must retain original expiration date.