Form Mv-664.1 - Persons With Disabilities Parking Permit - City Of Schenectady Page 4

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NOTE TO CUSTOMERS AND MEDICAL PROFESSIONALS
According to the NYS Vehicle and Traffic Law and the Penal Law, it is a crime (a felony or a
misdemeanor) to make a false statement or to provide false information on an application for a
parking permit or license plates for a person with severe disabilities. This crime is punishable by
a fine, imprisonment, or both. If this crime involves an application for a parking permit, the
crime may also result in liability for payment of a civil penality of $250 - $1,000.
For Customers Who Want License Plates, or a Parking Permit, for Persons with a Disability:
When you sign Part 1 of this application, you certify:
l
that the information you provide on this application is true;
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that you have read and understand the conditions for “Using License Plates and Parking Permits” stated
on page 2; and
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that you agree to comply with those conditions.
For Medical Professionals Who Provide Medical Information in Support of an Application for
License Plates, or a Parking Permit, for Persons with a Disability:
When you sign Part 2 of this application, you certify:
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that the medical information you provide is true and complete; and
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that, in your opinion, the person named in Part 1 of the application is medically qualified to receive
license plates, or a parking permit, for persons with a disability, according to the medical criteria
specified in Part 2.
MV-664.1 (2/14)
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