Form T20060-0117 - Application For Disabled Parking Placard/plate
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2MASSACHUSETTS REGISTRY OF MOTOR VEHICLES
Mail To: Medical Affairs - PO Box 55889 – Boston, MA - 02205-55889 – 857-368-8020 –
For Walk-In Service Only: Haymarket Center, 136 Blackstone Street, Boston, MA
APPLICATION FOR DISABLED PARKING PLACARD/PLATE
THIS SIDE OF THE APPLICATION MUST BE COMPLETED IN THE DISABLED PERSON’S NAME
Please note the information required in this application may affect your driver’s license status.
Incomplete applications will not be processed and will be returned.
Both disabled person and healthcare provider must sign and date this application. The disabled person’s information
must be provided in sections A, B, and C. The healthcare provider must complete sections D and E.
This application must be submitted to Medical Affairs within thirty (30) days of the healthcare provider’s certification.
RMV Service Center locations do not process disability parking applications; dropping off at a service center location may add
processing time.
Additional documentation may be required.
A. Disabled person’s information (please print)
Last Name
First Name
Middle
Gender
Residential Address
City/Town
Zip
Mailing Address
City/Town
Zip
Date of Birth
Social Security Number (SSN)
Height
Telephone Number
Mass Driver’s License or I.D. Number (if applicable) Current Placard Number (Expired or Extension of Current Placard)
B. I am applying for the following
Placard
No fee required for a placard. Disabled person is not required to have a vehicle registered in his/her name.
Plate
Only issued to individuals who have a vehicle registered in his/her name. Registration fees apply.
Motorcycle Plate
Only issued to individuals who have a vehicle registered in his/her name. Registration fees apply.
DV Plate
Only issued to individuals who: a) are primary owner with vehicle registered in their name; b) provide the DV
(Disabled Veteran) Plate Letter from the Veteran’s Administration listing service connected disabilities and total
combined rating; c) have qualifying conditions which meet Medical Affairs guidelines and total at least 60% of the
service connected disability.
C. Placard Rules and Acknowledgment
Rules:
It is illegal to allow someone to use your placard if you are not in the vehicle.
It is illegal for an individual to have more than one placard (temporary or permanent).
It is illegal to provide false information (persons can be prosecuted under Massachusetts Law).
It is illegal to possess or display a counterfeit placard (altered or photocopied).
It is illegal to forge a healthcare provider’s signature.
Acknowledgment:
I have read the rules listed above.
I understand misuse of disabled parking may result in high motor vehicle citation fines ($500, first offense), license suspension terms,
and the revocation of my disabled parking privileges.
I certify under the penalty of perjury that all the information provided in this application, including the representation of my medical
status/condition, is true and correct to the best of my knowledge.
AUTHORIZATION TO RELEASE MEDICAL RECORDS – I hereby authorize the healthcare provider completing this form to discuss
and release any or all medical records pertaining to its content with or to representatives of the RMV.
For applicants for DV plates, I hereby authorize the Veteran’s Administration to release medical information concerning my service
connected disability rating(s).
Signature of disabled person (REQUIRED)
Date: (REQUIRED)
T20060-0117
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