Form Mv5 - Disability Permit/license Plate Application

Download a blank fillable Form Mv5 - Disability Permit/license Plate Application in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Mv5 - Disability Permit/license Plate Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Print Form

Disability

MVD Use Only

Permit/License Plate

Expiration Date:

Permit #s:

Application

** See Page 2 for Instructions &

Special License Plate Information **

P.O. Box 201430 Helena MT 59620-1430 

Phone (406) 444-3933 Fax (406) 444-3816 

mvdtitleinfo@mt.gov

Applicant's Legal Name (first, middle, last) - please print (complete Sections A & B only)

Date of Birth

DL/ID/Tribal ID Number*

--OR-- Name of Organization Applying for Permit/Plate (complete Sections A & C)

FEIN or Corporate ID*

Mailing Address

City

State

Zip

Residential Address

City

State

Zip

You are eligible for one special parking permit and/or one set of license plates for each

Daytime Phone Number

noncommercial motor vehicle you own. If you do not own a motor vehicle, you can only receive one

special parking permit.

Number of Permits:

By submitting this form, the applicant certifies that: I have read pages 1 and 2 of this form and agree to comply with all the

requirements for the permit or license plate. I understand that by submitting this form, I am authorizing the State of Montana to

update my address and customer record.

Medical Certification for Individual:

This part must be completed by a licensed Physician, Physician's

Assistant, Chiropractor, or Advanced Practice Registered Nurse.

The Department of Justice shall issue a special parking permit to a person who has a disability that limits or impairs his/her mobility

(MCA 49-4-301, Eligibility for Special Parking Permit). The applicant must meet one or more of the following criteria (MCA 37-8-202):

cannot walk 200 feet without stopping to rest;

is severely limited in ability to walk because of an arthritic, neurological, or orthopedic condition;

is so severely disabled that the person cannot walk without the use of or assistance from a brace, cane, another person,

prosthetic device, wheelchair, or other assistive device;

uses portable oxygen;

is restricted by lung disease to the extent that forced expiratory respiratory volume, when measured by spirometry, is less than 1

liter per second or the arterial oxygen tension is less than 60 mm/hg on room air at rest;

has impairment because of cardiovascular disease or a cardiac condition to the extent that the person's functional limitations are

classified as class III or IV under standards accepted by the American Heart Association;

has a disability resulting from an acute sensitivity to automobile emissions or from another disease or physical condition that

limits or impairs the person's mobility and that is documented by the licensed physician, licensed physician's assistant, the

licensed chiropractor, or the licensed advanced practice registered nurse as being comparable in severity to the other conditions

listed in this subsection.

A person whose condition is expected to improve within six months will be issued a temporary permit for a period not to exceed six

months. If the condition exists after six months, an extended temporary permit may be issued not to exceed 24 months.

I certify that, based on the criteria listed above, the applicant is qualified for (check one):

Permanent permit (3-year period)

Temporary permit (6-month period)

Extended temporary permit (period of ____ months, maximum 24 months)

Printed Name: Physician/PA/Chiropractor/Advanced Practice RN

Type of Physician

Professional License Number

Address: Physician/PA/Chiropractor/Advanced Practice RN

City

State and Zip Code

Signature: Physician/PA/Chiropractor/Advanced Practice RN

Date

Daytime Phone Number

The Department of Justice may issue special parking permits to an agency or business that provides transportation as a service

for people with disabilities. The permits must be used only to load and unload people with disabilities.

Type of Organization (check one):

Skilled Nursing Facility

Nursing Home

Intermediate Care Facility

Other, explain:

We are applying for

permit(s).

I certify that I represent an agency, business, or long-term care facility that provides transportation as a service for people with

disabilities (MCA 49-4-301) and that I have full authority to sign for this agency, business, or facility (MCA 49-4-302).

Signature

Position Title

Printed Name

Date

Daytime Phone Number

*(If applicant has one): DL-Driver License No.; ID-Identification Card No.; FEIN-Federal Employer Identification No.; Tribal ID-Tribal Identification No.; Corp. ID-Corporate ID No.

Montana county and state authorities reserve the right to reject any form that has been altered.

MV5 (10/13) - Page 1 of 2

This form is available in alternate formats for people with disabilities.