State Form 42070 - Application For Disability Parking Placard Or Disability Plate

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APPLICATION FOR DISABILITY PARKING PLACARD OR DISABILITY PLATE

State Form 42070 (R3 / 4-97)

INDIANA BUREAU OF MOTOR VEHICLES

APPLICANT INFORMATION (Please Print)

Name of applicant (first, last, middle initial)

Address (number and street, city, state, ZIP code)

Federal ID number

Social Security number

Date of birth (month, day, year)

In accordance wih IC 4-1-8-1 disclosure of your Social Security number is MANDATORY, and this record cannot be processed without it. Confidential

information is being asked for herein due to IC 9-14-5.

SECTION 1 - APPLICATION FOR DISABILITY PLATE

(You must present this form at a License Branch within your county of residence to receive a Disability Plate)

A. I am qualified to receive a Disability Plate because (check one):

I have permanent disability that requires the use of a wheelchair, walker, braces or crutches.

I have permanently lost the use of one or both legs.

My mobility is permanently restricted due to a pulmonary or cardiovascular disability, arthritic condition, orthopedic condition or neurological

impairment. This requires the completion of SECTION 3A - "Practitioner's Certification" on the bottom of this form (a separate attachment is not

acceptable).

I am permanently blind or visually impaired as defined by IC 12-7-2-21 or 12-7-2-198. This requires the completion of SECTION 3B - "Practitioner's

Certification" on the bottom of this form by an optometrist or ophthalmologist (a separate attachment is not acceptable).

I have been issued a permanent parking placard under 9-14-5.

I affirm under the penalties of perjury that the foregoing representations are true (parent or legal guardian must

FOR BRANCH USE ONLY

sign for persons under the age of sixteen).

Date (month, day, year)

Signature

Plate number

NOTE: A person who knowingly and falsely represents himself as having the qualification to obtain a disability placard commits a Class C misdemeanor pursuant to IC 9-18-22-6.

B. If plate is issued to person other than the disabled person then the recipient of the plate must complete the following:

Name of applicant (first, last, middle initial)

Address (number and street, city, state, ZIP code)

Social Security number

In accordance wih IC 4-1-8-1 disclosure of your Social Security number is MANDATORY, and this record cannot be

processed without it. Confidential information is being asked for herein due to IC 9-14-5.

I affirm under the penalties of perjury that the vehicle to be registered with the plate applied for on this form is used regularly to transport the person qualifying

herself / himself as disabled on this form.

Date (month, day, year)

Signature

SECTION 2 - APPLICATION FOR DISABILITY PARKING PLACARD

(You must present this form at any Indiana License Branch to obtain a Disability Parking Placard.)

A. I am: (check one)

Applying for a new Disability Placard

Renewing my Disability Placard

Applying for a duplicate Disability Placard

Applying for an additional Disability Placard

B. I am qualified to receive a Disability Placard because (check one):

I have a disability that requires the use of a wheelchair, walker, braces or crutches.