City Of Chicago Taxicab Uniform Lease Agreement

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CITY OF CHICAGO UNIFORM TAXICAB LEASE AGREEMENT
FOR TAXICAB MEDALLION LICENSE NUMBER:
TX
THIS DOCUMENT MUST BE KEPT IN VEHICLE AT ALL TIMES and IS NOT VALID UNLESS COMPLETED AND SIGNED.
1.
Lease Type
(Check One Box)
12-Hour Daily Lease
12-Hour Weekly Lease
24-Hour Daily Lease
24-Hour Weekly Lease
Medallion License Only Lease
2.
Lease Term
________________
__________
________________
__________
FROM
TO
at
at
AM / PM
AM / PM
Start Date (MM/DD/YEAR)
Time (HH:MM)
End Date (MM/DD/YEAR)
Time (HH:MM)
CF#
3.
Public Chauffeur / Lessee Information
________________________________________________ _____________________________
Print First Name & Last Name
Phone Number with Area Code
________________________________________________ _____________________________
Lessee’s Signature
Date Signed (MM/DD/YYYY)
4.
Taxicab Vehicle Information
___________________ ___________________ ___________ __________________________
Make
Model
Model Year
Affiliation
Fuel Source:
Gasoline
Hybrid
CNG
Other_________________
WAV:
Yes
No
5.
Total Taxicab Lease Amount with GTT/Accessibility Fund and Worker’s Comp Fees:
VEHICLE
TOTAL
GTT &
LESSEE’S
TIER
LEASE
ACCESSIBLITY
WORKER’S
$
$
$
NUMBER
AMOUNT
FEE
COMP. INS.
6.
Lessor Listed Below is the
:
Medallion Manager
Medallion Owner
(Check One Box)
I certify that all the information on this lease is true, correct, and accurately reports the terms and conditions of the full taxicab lease agreement
in compliance with the Municipal Code of Chicago and applicable rules and regulations.
______________________________________________________________________________
If Applicable
Management Company Name (
)
________________________________________________ _____________________________
Lessor Name (
Please Print
)
Lessor 24-Hour Phone Number with Area Code
________________________________________________ _____________________________
Signature of Lessor
Date Signed (MM/DD/YYYY)
SEE PAGE 2 FOR LEASE RATES AND FEES INFORMATION
KEEP A COPY OF ALL LEASES FOR YOUR RECORDS ● REPORT LEASE OVERCHARGE COMPLAINTS TO 311
v.January.1.2016
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