Persons With Disabilities Parking Application Form Page 2

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JESSE WHITE

SIDE B

(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 disability plates and/or a parking placard. Complete

Parts 1 and 2 if the parent, immediate family member or legal guardian of the person with disabilities is applying for disabil-

ity plates.

PART 1. PERSON WITH DISABILITIES:

I hereby apply for:

____ 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 applica-

tion, whichever is applicable.) APPLICANTS MUST HAVE A PERMANENT DISABILITY TO OBTAIN DISABIL-

ITY PLATES.

____ Persons with Disabilities Parking Placard

under the statutory provision (625 ILCS 5/1-159.1), and certify that my physical condition entitles me to the issuance

thereof. I also am aware that the person with disabilities parking device (plates or parking placard) must not be used

unless I am the driver or passenger in the vehicle.

__________________

____________________________________________

Date

Applicantʼs Signature

WARNING: MISUSE OF OR FALSE APPLICATION FOR PERSONS WITH DISABILITIES PLATES OR PARKING PLACARDS may

result in revocation of the plates or placard, a 30-day driverʼs license suspension, and a fine of up to $1,000. The authorized

holder of the disability plates or parking placard must be present and must enter or exit the vehicle at the time parking privi-

leges are being used.

PLEASE PRINT OR TYPE BELOW:

Name of Person with Disability

Date of Birth (Month/Day/Year)

__________ OR __________

Male

Female

Address

City

ZIP

Driverʼs License or State ID Card Number of Person with Disability

Telephone Number

PART 2. DISABILITY LICENSE PLATES FOR PARENT, IMMEDIATE FAMILY MEMBER OR LEGAL GUARDIAN ONLY:

I hereby apply for disability license plates as the parent, legal guardian or other family member 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.

Parentʼs, Legal Guardianʼs OR Family Memberʼs Name

Date

Address

City

ZIP

Telephone Number

Relationship to Person with Disability

(

)

............................................................................FOR OFFICE USE ONLY............................................................................

Parking Placard Number ______________________________________ Expiration Date _________________________

Issued By __________________________________________________ Issue Date_____________________________

♻ Printed on recycled paper. Printed by authority of the State of Illinois. February 2011 — 100M — VSD 62.21