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APPLICATION FOR A METERED PARKING WAIVER

FOR PERSONS WITH SEVERE DISABILITIES

Instructions for completing this application are on page 2. Take the completed application to the issuing agent in the area where you

live. Please bring your New York State driver license with you when you apply for the waiver.

INFORMATION ABOUT PERSON WITH DISABILITY

— (Please print, and sign by the arrow.)

Last Name

First

M.I.

Date of Birth

Male

Female

Telephone No.

Address: No. and Street

Apt. No.

City

State

Zip Code

(

)

Driver License Number and Expiration Date: __________________________________________________________

Do you have license plates for persons with disabilities?

Yes, plate number is:_____________________

Do you have a parking permit for persons with disabilities?

Yes, permit number is:____________________

By signing this form I certify that I meet the requirements for a metered parking waiver. I understand that making a false statement

or providing misinformation on an application to obtain or facilitate the receipt of a metered parking waiver for people with

disabilities may result in a civil penalty ranging from $250-$1,000 and/or criminal prosecution and penalties.

If signed by a parent or

(Date)

(Signature of Person with Disability or Signature of Parent or Guardian) —

guardian, please state your relationship to the person with the disability after your signature.

MEDICAL CERTIFICATION—

This section must be completed only by a physician, physician assistant (PA), or doctor of

osteopathy (DO).

The metered parking waiver is available to people who are severely disabled as defined in Vehicle and Traffic Law Section 404-a

(see Part A) AND who also have a disability that hinders their ability to put payment into a parking meter (see Part B).

F Part A

Uses portable oxygen

Legally blind

Limited or no use of one or both legs

Unable to walk 200 ft. without stopping

Neuromuscular dysfunction that severely limits mobility

Class III or IV cardiac condition. (American Heart Association standards)

Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition

Restricted by lung disease to such an extent that 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 of room air at rest

Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability,

and which imposes unusual hardship in the use of public transportation and prevents the person from getting around

without great difficulty.

F Part B

Please certify that the severely disabled patient (as described in Part A) also has a severe disability

that limits one or more of the following (check all that apply):

Fine motor control of both hands

Ability to reach or access a parking meter due to use of a wheelchair or other ambulatory device

Ability to reach a height of 42 inches from the ground due to lack of finger, hand, or upper extremity strength or

mobility.

Physician/PA/DO Name (Print/Type)

Professional License No.

Physician/PA/DO Address (Print/Type)

Telephone No.

(

)

By signing this form I certify that this severely disabled patient (as defined by NYS Vehicle and Traffic Law Section 404-a) has a

disability limiting one or more of the actions listed in Part B above. I understand that making a false statement or providing

misinformation on an application to obtain or facilitate the receipt of a metered parking waiver for people with disabilities may

result in a civil penalty ranging from $250-$1,000 and/or criminal prosecution and penalties.

(Physician/PA/DO Signature)

(Date)

File Information (For Issuing Agent Use Only)

MV-664MP No. Issued: __________________ Date Issued:_______________ MV-664 No. Issued: ____________________

PAGE 1 OF 2

MV-664.1MP (2/17)

Form Mv-664.1mp - Application For A Metered Parking Waiver For Persons With Severe Disabilities

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