Application For Illinois Disabled Person Identification Card
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2State of Illinois • JESSE WHITE • Secretary of State
Application For Illinois Disabled Person Identification Card
I am applying for an Illinois Disabled Person Identification Card at no fee on the basis that I am an individ-
ual who is disabled as defined in Section 4A of the Illinois Identification Card Act.
I affirm that the information in this affidavit is true and correct.
Applicant's Signature/Date _____________________________________________________________________________________
Driver’s License Number
and/or
Identification Card Number
___________________________________________________
_________________________________________________
___________________________________________________
_________________________________________________
Witness
Witness
Certification for Illinois Disabled Person Identification Card
Below please indicate the Type of Disability and Classification of Disability pertaining to the applicant
named on this affidavit. Refer to the Definition Supplement on the reverse for assistance. (Please mark
only one type and one classification .)
Type of Disability
Classification of Disability
K Physical (P)
K Class 1
K Developmental (D)
K Class 1a
K Visual (V)
K Class 2
K Hearing (H)
K Class 2a
K Mental (M)
I hereby certify that the conditions of the disabled person named herein are determined and defined under
Chapter 15, Illinois Compiled Statutes, Section 335/4A.
__________________________________________________________
Physician’s Signature / Date
__________________________________________________________
Physician Assistant’s/Advanced Practice Nurse’s (APN) Signature / Date
(PLEASE PRINT OR TYPE BELOW)
Physician’s Name
Phone
Address
Applicant’s Name
Date
Driver’s License or ID Number
Control Number
MISUSE OF A DISABLED ID CARD CAN RESULT IN ITS REVOCATION
* Please submit this completed form at your local Driver Services facility.
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