Form VSD415.9 "Application for Replacement Disability Parking Placard" - Illinois

Form VSD415.9 is a Illinois Secretary of State form also known as the "Application For Replacement Disability Parking Placard". The latest edition of the form was released in March 1, 2016 and is available for digital filing.

Download a fillable PDF version of the Form VSD415.9 down below or find it on Illinois Secretary of State Forms website.

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Download Form VSD415.9 "Application for Replacement Disability Parking Placard" - Illinois

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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.
www.cyberdriveillinois.com
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.
Printed by authority of the State of Illinois. March 2016 — 2.5M — VSD 415.9
Print
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.
www.cyberdriveillinois.com
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.
Printed by authority of the State of Illinois. March 2016 — 2.5M — VSD 415.9
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