Form Tr-159-Disabled Placard-Plate Application printable pdf download

KANSAS

DISABLED PLACARD AND/OR PLATE

Department of Revenue

Division of Vehicles

APPLICATION

Topeka, Kansas 66626-0001

Name of Disabled Individual,

Business or Agency

Physical

Address

City

KS ZIP

Individual’s ONLY:

Date of Birth

Sex:

Male

Female

Other

I have read the front and back of this application.

Applicant’s Signature

Phone No. (

)

Date

PLEASE CHECK APPROPRIATE APPLICATION(S):

1. DISABLED IDENTIFICATION PLACARD APPLICATION

PERMANENT (Fee: $6.00 each); TEMPORARY (Fee: $5.00 each)

Check here only if applying for (lost, stolen) replacement placard.* No Licensed Professional’s Statement needed for replacement placard.

*If Replacement Placard, Current Disabled ID Card Number

2. DISABLED LICENSE PLATE APPLICATION (FEE: $4.00)

plus 50¢ reflectorized plate fee

Only applicants certified as PERMANENT disabled may apply for a disabled license plate.

BUSINESS OR AGENCY REPRESENTATIVE MUST CERTIFY AND SIGN THE FOLLOWING:

I, the undersigned, certify that the above named agency or business is responsible for the transportation of person(s) to be considered disabled as per K.S.A. 8-1,124, as out

lined below, thus qualifying for accessible parking privileges.

Authorized Representative or Owner Signature

Title

Date

( Rubber Stamp NOT Acceptable)

HEALING ARTS LICENSED PROFESSIONAL’S STATEMENT

Attending licensed professional must certify and sign the following:

I, the undersigned licensed professional, certify that

(Disabled Individual’s Name)

is considered to be disabled, as per Kansas Statute 8-1,124, due to at least one (1) or more of the following: (Must check at least one.)

1. Has a severe visual impairment;

2. Cannot walk one hundred (100) feet without stopping to rest (Violation KSA 8-1,130);

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

assistive device;

4. 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 one liter, or the arterial oxygen tension is less than sixty mm/hg on room air at rest;

5. Uses portable oxygen;

6. Has a cardiac condition to the extent that the person’s functional limitations are classified in severity as Class III or Class IV

according to standards set by the American Heart Association;

7. Severely limited in their ability to walk at least 100 feet due to an arthritic, neurological, or orthopedic condition.

I certify that I am aware of the penalties provided by KSA 8-1,130(b) listed on the back of this application.

Licensed Professional’s Signature*

Medical Title

Date

(Rubber stamp not acceptable)

The following are the only professionals that can sign this form: Dr. of Medicine (MD), Dr. of Osteopathy (DO), Dr. of Chiropractic (DC), Dr. of Podiatric

(DPM), Licensed Optometrist (OD), or Christian Science practitioner listed in The Christian Science Journal. (KSA Chapter 65, Article 28 and 8-1,125)

MUST check one (1) of the following and provide requested information:

PERMANENT

TEMPORARY**

From (Date)

To (Date)

** Six (6) Months is the MAXIMUM Duration for a Temporary Placard.

Printed / Typed Name

of Licensed Professional

(

)

Phone No.