Form Mv-90 - Disabled Person'S Parking Affidavit

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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.
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’
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?
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
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 #
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
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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