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Form Mv-663 - Certification For An Additional Set Of License Plates For Persons With Disabilities

CERTIFICATION FOR AN ADDITIONAL SET OF

LICENSE PLATES FOR PERSONS WITH DISABILITIES

A registrant is entitled to an additional set of license plates for persons with disabilities (that is, plates

with the International Symbol of Access logo on them) if ALL of the following conditions are met:

1. the disabled REGISTRANT must:

a. already have license plates for persons with disabilities on his/her vehicle.

b. have another vehicle registered in his/her name.

c. have another family member who is disabled.

2. the disabled FAMILY MEMBER must:

a. live with the registrant.

b. be the usual licensed driver of the vehicle for which the additional set of license plates

for persons with disabilities is being requested.

c. qualify as severely disabled, and provide a physician’s statement to that effect (to be

attached to the registrant’s application).

Disabled registrant requesting an additional set of license plates:

Last Name

First

M.I.

Driver License ID Number

Plate Number for First Set of License Plates

Disabled family member for whom license plates are requested:

Last Name

First

M.I.

Driver License ID Number

Relationship to Disabled Registrant

CERTIFICATION

I certify that these plates will be used according to the conditions specified in 1 and 2 above.

Date

____________________________________________________________________

__________________________

Signature of Disabled Registrant (Sign Name in Full)

MV-663 (9/15)

Form Mv-663 - Certification For An Additional Set Of License Plates For Persons With Disabilities