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APPLICATION FOR DISABILITY PARKING PLACARD OR DISABILITY PLATE

State Form 42070 (R6 / 7-07)

INDIANA BUREAU OF MOTOR VEHICLES

The information in this document is confidential according to IC 9-14-5.

* Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is voluntary and you will not be penalized for

refusal.

INSTRUCTIONS: Please print or type

APPLICANT INFORMATION

Name of applicant (first, last, middle initial) (if corporation or agency, list name)

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

Federal Identification number

Social Security number *

Date of birth (month, day, year)

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 IC 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)

Social Security number *

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

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.

Temporarily

Permanently

I have lost the use of one or both legs.

Temporarily

Permanently

My mobility is restricted due to a pulmonary or cardiovascular disability, arthritic condition, orthopedic condition or neurological impairment. (This

requires the completion of SECTION 3A of the Practitioner's Certification on the back of this form. A separate attachment is not acceptable.)

Temporarily

Permanently

SECTION 2B continued on the reverse side of this form.