Fillable Form Mv-90 - Disabled Person'S Parking Affidavit printable pdf download

Disabled Person’s Parking Affidavit

MV-9D (Rev. 05-2006)

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).

*Vehicle Owner’s Full Legal Name

*Driver’s License # & Name of Issuing State

*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 Street Address including city, state & zip

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 a Disabled Person’s License Plate with this form.

□

Temporary Parking Permit (Placard) No Fee – Not valid for more than six (6) months.

□

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 the practitioner of the healing arts as defined in

Georgia Law

§40-6-221(5.1), as amended.

Is disability permanent?

Yes

I hereby swear and affirm that the above individual as defined by

Georgia Law §24-9-101

and §40-6-221(5):

□

Is hearing impaired pursuant to

Georgia Law

§24-9-101.

□

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

□

Cannot walk without the use of or 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 a 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 an angle of no

greater than twenty-degrees (20).

□

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

Section Five – Certification

Practitioner of the Healing Arts’ Printed Name

GA License #

Signature

Date

Office Street Address including city, state & zip

Telephone# including area code

(

)

Note: Notarization Required For Practitioner of the Healing Arts’ Signature

Sworn to and subscribed before me

Notary Public’s Signature & Notary Seal or Stamp

This __________day of ______________________, _____________

Date My Notary Commission Expires

(Day)

(Month)

(Year)

County and State Use Only

Inventory# ___________________

Issue Date ___________________

Replacement Permit? Yes* □ No □ * If yes, Replacement Permit #___________________

New Application? □ Yes

□ No

*Retention Schedule: This form will be retained at the County Tag Office for two (2) years from the date issued.

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Form Mv-90 - Disabled Person'S Parking Affidavit

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