Form Tr-159 - Certification Of Disability For Disabled Parking Placard And/or Plate

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CERTIFICATION OF DISABILITY FOR
KANSAS
DISABLED PARKING PLACARD AND/OR PLATE
Department of Revenue
Division of Vehicles
Application for disabled placards, plates and ID card must be made at
YOUR County Treasurer's Local Motor Vehicle Office
Name of Disabled Individual,
Business or Agency
Physical
Address
City
KS ZIP
Individual’s ONLY:
Date of Birth
Sex:
Male
Female
Applicant’s
Phone
Signature
Number:
Date
PLEASE CHECK APPROPRIATE APPLICATION(S):
1. DISABLED IDENTIFICATION PLACARD APPLICATION
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 (50¢ reflective 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(a)(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), licensed physician assistant (PA), advanced registered nurse practitioner (ARNP) registered under KSA 65-1131 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 below and provide requested information:
TEMPORARY**
PERMANENT
From (Date)
To (Date)
.
** Six (6) Months is the MAXIMUM Duration for a Temporary Placard
.
Printed / Typed Name
of Licensed Professional
Phone No.
May be signed by a Healing Arts Professional licensed in any state.
Printed:
Address
City
State
ZIP
SEE REVERSE SIDE FOR INSTRUCTIONS
TR-159www (Rev.1003)

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