Form Rdmv130 - Walking Disability Privileges Application Form

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STATE OF NEW HAMPSHIRE

DEPARTMENT OF SAFETY

Division of Motor Vehicles

23 Hazen Drive, Concord, NH 03305-0001

John J. Barthelmes

Elizabeth A. Bielecki

APPLICATION FOR WALKING DISABILITY PRIVILEGES

Commissioner of Safety

Director of Motor Vehicles

Section I – Disabled Person’s Information

This section must be completed and may be signed by any one of the following:

The applicant.

The applicant’s power-of-attorney. (Please attach copy of POA documentation.)

The applicant’s guardian. (Please attach copy of guardianship documentation.)

The applicant’s parent, if the applicant is under age 18. (Please attach copy of birth certificate.)

Name: __________________________________________________________________

____________________________

First

Middle Initial

Last

Date of Birth

Mailing Address: ______________________________________________________________________________________________

Street

City

State

Zip Code

____________________________

__________________________

____________________________________

Driver License or

Non-Driver ID #

Phone Number

E-Mail Address (Optional)

(Please write “none” if you do not have one.)

If this application is approved, one placard will be issued at no charge.

Please check here if you would like an additional placard at no extra charge.

(If applying for or if you already have a walking disability plate, you are not eligible to receive an additional placard.)

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 pursuant to RSA 261:88.

_________________________________________________________________

__________________________

Signature

Date

Section II – Medical Provider Information

This section must be completed by your medical provider.

Please CHECK ONE of the following:

Please issue a placard for a TEMPORARY disability for a period of _____ months. (Cannot exceed 6 months.)

Please issue a placard for a PERMANENT disability. (These placards require periodic renewal/recertification per RSA 261:88.)

Please CHECK ONE of the following:

I am a:

Licensed Physician

Podiatrist

Advanced Practice Registered Nurse (ARNP)

Physician’s Assistant

Please CERTIFY as follows:

I certify, under penalty of unsworn falsification pursuant to RSA 641:3, that the person whose name appears above is under my

treatment/care and, in my professional opinion, has a walking disability as defined/used under RSA 259:124 and RSA 261:88. RSA

261:88 includes the following criteria:

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 60 mm/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 standards set by the

American Heart Association; or

V. Is severely limited in the ability to walk due to an arthritic, neurological, orthopedic, or other medically debilitating condition. Cannot walk without the use of, or

assistance from, a brace, cane, crutch.

Medical Provider Name (printed legibly): _______________________________________ Phone #:__________________________

Medical Provider Address: _____________________________________________________________________________________

Medical Provider Signature (original required): ______________________________________________ Date: ________________

Phone: (603) 227-4030

TDD Access: Relay NH 7-1-1

RDMV130 (Rev 04/16)