Form Mv-145a - Person With Disability Parking Placard Application
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2MV-145A (8-16)
FOR DEPARTMENT USE ONLY
Bureau of Motor Vehicles • P.O. Box 68268 • Harrisburg, PA
ChECK ( 4 ) APPROPRIATE bLOCKS bELOW
17106-8268
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ORIGINAL REQUEST -
Permanent Placard
Severely Disabled Veteran
Temporary Placard
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RENEWAL REQUEST - (For Permanent Placards Only)
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REPLACEMENT REQUEST -
PLACARD
ID CARD
Defaced
Lost
Stolen
Never Received
PREVIOUS PLACARD # __________________
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ChANGE OF ADDRESS - Complete Sections A and E. NOTE: Notarization is not required.
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ChANGE OF NAME - Complete Sections A and E. Check here to indicate reason for change of name:
Marriage
Divorce
Other: ______________________
APPLICANT INFORMATION - LIST NAME AND ADDRESS OF PERSON WITh DISAbILITY - NOTE: If listing
an out-of-state address, you must also
A
complete and attach Form MV-8.
Last Name (or Full Business Name)
First Name
Middle Name
PA DL/Photo ID#
Date of Birth
or Bus. ID#
Street Address
City
State
Zip Code
Email Address
NOTE: If you are the parent or adult charged by law with the natural parent’s rights, duties and responsibilities acting on behalf of a minor child (under 18) in place of the child’s natural parents (person in
loco-parentis), you must complete the information below.below. In addition, a parent, including an adoptive or foster parent who has custody care or control of the child or adult child or a spouse may sign
on behalf of the child, adult child or spouse (applicant) provided the applicant meets eligibility requirements (1) through (8).
CERTIFICATION FROM A hEALTh CARE PROVIDER LICENSED OR CERTIFIED IN PA OR A CONTIGUOUS STATE (NEW YORK, NEW JERSEY, DELAWARE, MARYLAND, WEST VIRGINIA OR
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OhIO). ThIS SECTION MUST bE COMPLETED IN FULL. hEALTh CARE PROVIDERS MAY ONLY CERTIFY DISAbILITIES WIThIN ThEIR SCOPE OF PRACTICE. WARNING: Altering or forging a
document issued by the Department, such as a disabled person parking placard, or possessing, using or displaying, such a document knowing it to have been altered, forged or counterfeited,
is a misdemeanor of the first degree pursuant to the Vehicle Code, 75 Pa.C.S. Section 7122, punishable by a fine of not more than $10,000 or imprisonment of not more than five years, or both.
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I hereby certify that the person with the disability listed above is under my care and has the following condition listed on the reverse side of this
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application under “Eligibility Requirements”: _______________ (NOTE: Only those conditions listed on the reverse side of this application qualify
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an applicant for a person with disability placard.)
List Reason Code # Here
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NOTE: If reason code #1 is listed above, please indicate the individual's visual acuity by completing the chart to the right:
CORRECTED
If reason code #4 is listed above, please indicate the type of device used: ________________________________________________
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Temporary placards are only issued for a period of time not to exceed six months. If the applicant requires additional time after the expiration of
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the placard issued, the applicant must be recertified by a health care provider.
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Medical License No.
health Care Provider’s Printed Name
health Care Provider’s Signature
Office Street Address
City
State
Zip Code
CERTIFICATION bY POLICE OFFICER - Police officer may only certify that the applicant does not have full use of a leg or both legs, or is blind.
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NOTE: If Section b above is completed, please skip this Section and go on to Section E.
This is to certify that the person with disability listed above has the condition listed and is entitled to the use and privileges of the person with disability
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OR
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is blind,
does not have full use of a leg or both legs as evidenced by the use of a:
parking placard.
wheelchair
walker
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crutches
cane/quad cane
other prescribed device
Officer’s Printed Name
Officer’s Signature
badge Number
Office Street Address
City
State
Zip Code
Telephone Number
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)
D
CERTIFICATION FROM U.S. DEPARTMENT OF VETERANS AFFAIRS REGIONAL OFFICE ADMINISTRATOR (PhILADELPhIA OR PITTSbURGh)
OR SERVICE UNIT IN WhICh ThE VETERAN SERVED OR A LEGIbLE PhOTOCOPY OF ThE APPLICANT'S LETTER OF PROMULGATION OR
AWARDS LETTER.
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This is to certify that the veteran listed above with VA number ___________________________, has a 100% service-connected disability or has the
following service connected disability reason code number _______, listed on the reverse side of this application under “Eligibility Requirements.”
NOTE: If reason code #4 is listed, please indicate the type of device used: __________________________.
Authorized Printed Name and Title: ____________________________________________ Authorized Signature: ____________________________________________
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In lieu of the U.S. Department of Veterans Affairs Regional Office Administrator certification, I have attached a legible photocopy of my Letter of
Promulgation or Awards Letter that indicates I have a 100% service-connected disability.
E NOTARIZATION AND APPLICANT SIGNATURE - Applicant, natural parent or other authorized person listed in Section A must sign below.
I state that I have read and signed this application after its completion, and I swear or
SUBSCRIBED AND SWORN
affirm that the statements made herein are true and correct, and that any statement
TO BEFORE ME:
MONTH
DAY
YEAR
made on or pursuant to this application is subject to the penalties of 18 Pa.C.S.
Section 4903 (a)(2) (relating to false swearing), which shall include punishment of a
fine not exceeding $5,000, or to a term or imprisonment of not more than two years,
SIGNATURE OF PERSON ADMINISTERING OATH
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or both.
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SIGN IN PRESENCE OF NOTARY
A
Applicant Signature
Date
Telephone Number
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ThIS APPLICATION MAY bE DUPLICATED
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