Traffic Control Device - Deaf Child Area

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M`1'' I+ SO�f� U1 BEal" P 4�44 MAC Vie. "I 1 11�"IL+ 1 ]t�lp; I11�sS' C" 14'D'll ��".ii w ILII. L) SIG I request that a deaf child sign be posted within the public right,of way of my place of residence, and I understand that only one sign per approach is permitted with exact placement to be determined by the South Bend City Engineer. I also understand that installation could take 90 days from the date of submission. In support of this request, I hereby certify under pains and penalties for perjury that I am the parent, guardian, or person responsible for the care of a deaf child under age 13 and in whose home this deaf child regularly resides. I further certify that the deaf condition of this child has been confirmed by hearing tests or by a medical professional. By signing this Request, I agree to immediately notify the City in writing if (i) the family moves from the area, (ii) the child no longer lives ill the area, and (iii) any conditions related to significant improvement in the child's hearing; have occurred. I understand the sign will be removed when the child reaches the age of 13. Date; Signature _. ..__.�.. ... Printed Natne and Relationship to Child Mother 574-807-5693* Phone Number Na:-VVI.U.YI CAI..YYVC-S Ghild's Narne Street Address of Residence for mm. , c tt Sign Placement City and Zip Code m.. de CAO.... co n/1 Email Child's llate of Birth If the above address is not your actual physical residence, then please provide actual address for contact., Return this forrri to City of South Bend, Department of Public Works, 1300 N County -City Building, 227 W. Jefferson Blvd,, South ]..lend, IN 46601 Please make a copy for your records.