Fillable Form Mv-9d - Disabled Person'S Parking Affidavit printable pdf download

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Disabled Person’s Parking Affidavit

MV-9D (rev. 1-2013)

motor.etax.dor.ga.gov

_______________

New

Renewal

Section One - Except for signature(s), this form must be typed, electronically completed and printed or legibly hand printed.

Note: The vehicle owner information is only required when applying for a DP license plate. You do not have to own a vehicle to obtain a DP parking permit

(placard). Apply at the Tag Office in the county in Georgia where you reside.

* Vehicle Owner’s Full Legal Name

* Driver’s License # & Name of Issuing State (person operating vehicle)

*Vehicle Owner’s Street Address including city, state & zip

*County of Residence

Disabled Person’s Full Legal Name

*Relationship to Vehicle Owner- Check only one box

Child

Self

Spouse

Ward

* Disabled Person's Driver’s License # & Name of Issuing State(if applicable)

Disabled Person’s Street Address including City, State & ZIP

Active Military Duty

Retired GA Veteran

Section Two - For Institutions Only: This vehicle is used primarily for the transportation of disabled persons.

Institution’s Full Legal Name (Institution as defined by Georgia Law §31-7-1)- Attach a copy of institutional license

Vehicle Year & Make

Vehicle Identification #

Vehicle Color

Vehicle Tag #

Institution Authorized Representative’s Signature & Position –‘PARKING PERMITS (Placards) ONLY’

Date

Section Three

Check applicable box(s) below: You may apply for both a Disabled Person’s Parking Permit and Disabled Person’s License Plate with this form.

Temporary Parking Permit (Placard) No Fee-Termination date of disability: ______________________________________

Permanent Parking Permit (Placard) No Fee- Must be replaced every four (4) years from issue date.

Special Permanent Parking Permit (Placard) No Fee-Because of a physical disability, drives a motor vehicle which has been equipped with hand controls for

the operation of the vehicle’s brakes and accelerator; or is physically disabled due to the loss of, or loss of use of, both upper extremities. Must be replaced

every four (4) years from issue date.

Disabled Person’s License Plate (Fee $20.00 plus any taxes that may be due).

Section Four - To be completed by a licensed doctor of medicine, osteopathic medicine, podiatrist, optometrist or a licensed chiropractor.

Is disability permanent?

Yes

No-Temporary permits shall be issued for no more than 180 days

I hereby swear and affirm that the above individual as defined by Georgia Law §24-9-101 and §460-6-221(5):

Is so ambulatory disabled that he/she cannot walk 200 feet without stopping to rest.

Cannot walk without use of assistance from a brace, a cane, a crutch, another person, a prosthetic device, a wheelchair, or other assistive device.

Is restricted by lung disease to such an extent that his/her forced respiratory volume for one second, when measured by spironmetry is less than one liter, or

when at rest his/her arterial oxygen tension is less than 60 millimeters of mercury on room air.

Uses portable oxygen.

Has a cardiac condition to the extent that his/her functional limitations are classified in severity as Class III or Class IV according to standards set by the

American Heart Association.

Is severely limited in his/her ability to walk due to an arthritic, neurological, orthopedic condition or complications due to pregnancy.

Is hearing impaired pursuant to Georgia Law §24-9-101.

Is blind individual whose central visual acuity does not exceed 20/200 in the better eye with correcting lenses or whose visual acuity. If better than 20/200, is

accompanied by a limit to the field or vision in the better eye to such degree that is widest diameter subtends and angle of no greater than twenty-degrees(20).

Section Five - Certification

Licensed Doctor’s Printed Name

Doctor’s License #

State of Issuance

Signature

Office Street Address including City, State & ZIP

Telephone # including area code

Note: Notarization Required For Licensed Doctor’s Signature

Sworn to and subscribed before me

Notary Public’s Signature & Notary Seal or Stamp

This ________ day of ______________________, ______

Date My Notary Commission Expires