Form Rdmv 130 - Application For Walking Disability Privileges Form

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NEW HAMPSHIRE APPLICATION

FOR WALKING DISABILITY PRIVILEGES

Incomplete applications cannot be processed.

Both disabled person and medical professional signatures are required.

1. Disabled Person’s Information: (Please Print)

NAME:

FIRST

MIDDLE

LAST

DATE OF BIRTH

MAILING ADDRESS:

STREET

CITY/TOWN

STATE

ZIP CODE

DRIVER LICENSE NUMBER / NON

BEST CONTACT PHONE

EMAIL ADDRESS

DRIVER IDENTIFICATION NUMBER

NUMBER (RECOMMENDED)

I am applying for one of the following: (Check all that apply)

One placard (no charge).

Additional placard (no charge, maximum of 2 placards per resident).

Walking Disability Plate ($8 fee for initial issuance, no fee for renewals. Permanent Disability only, must complete section 3).

Walking Disability Vanity Plate (Permanent Disability only, must complete section 3 below and an Application for Initial Plates

(RDMV120).

I, the undersigned applicant, certify under penalty of unsworn falsification pursuant to RSA 641:3, that I am a resident of this State

qualified for Walking Disability Privileges.

Applicant OR Power of Attorney Signature: _____________________________________ Date:______________

NOTE: Power of Attorney must supply appropriate documentation, including a copy of the Power of Attorney.

2. Medical Provider Information: Please check only one:

Permanent

Temporary: for a period of ______ Months (cannot exceed six (6) months)

I certify the above applicant meets one of the criteria listed below:

Cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other

assistive device, or:

II.

Is restricted by lung disease to such an extent that the person’s forced (respiratory) expiratory volume for one second, when measured

by spirometry, is less than (1)liter, or the arterial oxygen tension is less than 60mm/hg on room air at rest; or

III. Uses portable oxygen; or

IV. Has a cardiac condition to the extent that the person’s functional limitations are classified in severity as class 3 or class 4 according to

the standards set by the American Heart Association; or

Is severely limited in the ability to walk due to an arthritic, neurological, orthopedic, or other medically disabling condition.

I certify, under penalty of unsworn falsification, that the person whose name appears is under my treatment and care and in my

professional opinion has a walking disability as defined under RSA 259:124.

I am a:

Licensed Physician

Podiatrist

Advanced Practice Registered Nurse (APRN)

Physicians Assistant

Physician’s Address: ____________________________________________________________________________________________

Print Name: __________________________________________________ Contact Phone Number: _____________________________

Signature: ___________________________________________________ Date: ___________________________________________

3. Walking Disability Plate Information:

Submit a copy of the current registration of the vehicle

you wish to obtain plates for and a completed Application for Initial Plates

(RDMV 120):

This is my own vehicle.

This vehicle is registered to a relative residing in my household and provides primary transportation for me.

Household Member Information:

Print Name:___________________________________________ DOB:_______________ Relation to Applicant: _______________

I certify under penalty of unsworn falsification pursuant to RSA 641:3, that I provide primary transportation for the named applicant, as a

member of that relative’s household.

Vehicle Owner’s Signature: ____________________________________ Date:___________________________

NOTE: Power of Attorney must supply appropriate documentation, including a copy of the Power of Attorney.

_________________________________________________________________________________________________________________________________________________________________________________________

By mail, please submit all documentation to NH DMV Attn: Walking Disability, 23 Hazen Drive, Concord, NH 03305-0001

If applying in person, you may bring your application to any DMV substation as listed at

Please make Checks payable to: State of NH-DMV

Phone: (603) 227-4000

RDMV130 (Rev 09/14)