Persons With Disabilities Parking Application Form
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JESSE WHITE
SIDE A
(To be completed by physician)
Secretary of State • State of Illinois
Persons with Disabilities Certification for Parking Placard
DIRECTIONS: Both sides of this document must be signed and completed. Side A must be completed by the physician and
Side B must be completed by the applicant.
DEFINITION: “PERSONS WITH DISABILITIES” (625 ILCS 5/1-159.1)
“A natural person who, as determined by a licensed physician: (1) cannot walk without the use of, or assistance from, a
brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device; (2) is restricted by lung dis-
ease to such an extent that his or her forced (respiratory) expiratory volume for one second, when measured by spirome-
try, is less than one liter, or the arterial oxygen tension is less than 60 mm/hg on room air at rest; (3) uses portable oxygen;
(4) has a cardiac condition to the extent that the personʼs functional limitations are classified in severity as Class III or Class
IV, according to the standards set by the American Heart Association; or (5) is severely limited in the personʼs ability to walk
due to an arthritic, neurological, or orthopedic condition; or (6) cannot walk 200 feet without stopping to rest because of one
of the above 5 conditions; or (7) is missing a hand or arm or has permanently lost the use of a hand or arm.”
Please fill in the name of the person with the disability, state the diagnosis, and indicate the impairments below.
Name of Person with Disabilities: ____________________________________________________________________
Diagnosis:________________________________________________________________________________________
NOTE: “Cannot walk 200 feet without stopping to rest” is no longer a qualifying disability unless it is related to one of the
following conditions below.
____ Is restricted by lung disease to such a degree that the personʼs forced (respiratory) expiratory volume (FEV) in one
second, when measured by spirometry, is less than one liter.
____ Uses portable oxygen.
____ Has a Class III or Class IV cardiac condition according to the standards set by the American Heart Association.
____ Cannot walk without the assistance of another person, prosthetic device, wheelchair or other assistive device.
____ Is severely limited in the ability to walk due to an arthritic, neurological or orthopedic condition.
____ Has permanently lost the use of or is missing a hand or arm.
LENGTH OF DISABILITY: (check one)
❏ Disability is permanent (Note: Form must be mailed to the Springfield address below.)
❏ Disability is temporary; must state duration (maximum 6 months) _________________
(Note: Form may be taken to any Secretary of State facility or mailed to the Springfield address below.)
I hereby certify that the physical condition of the person with disabilities listed herewith constitutes him/her as a person with
disabilities as described under 625 ILCS 5/1-159.1. WARNING: Any person who knowingly misuses or makes a false or
misleading statement on an application may be fined up to $1,000. PHYSICIANS: Do not sign this form if the patient
does not meet the above definition. (NOTE: If certification form is signed by a licensed physician assistant or advance
practice nurse, the name and license number of the supervising physician is required.)
_______________________________________________
_______________________________________________
Physicianʼs Signature
Date
Physicianʼs License Number
_______________________________________________
_______________________________________________
Supervising Physician's Name
Date
Supervising Physicianʼs License Number
PLEASE PRINT OR TYPE BELOW:
Physicianʼs Name __________________________________________________________________________________
Address __________________________________________________________________________________________
City________________________________________________State__________________ZIP_____________________
Telephone (
) _______________________________________________________________________________
Please mail all required documentation to: Secretary of State, Persons with Disabilities License Plates/Placard
Unit, 501 S. Second St., Rm. 541, Springfield, IL 62756, .com.
♻ Printed on recycled paper. Printed by authority of the State of Illinois. February 2011 — 100M — VSD 62.21
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