Disabled Veteran Certification For Va Plates
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JESSE WHITE
Secretary of State • State of Illinois
Disabled Veteran Certification for Parking Placard/License Plates
DIRECTIONS: Both sides of this document must be signed and completed. Applicants complete the appropriate section (Part 1 for
applicant). Your physician, advanced practice nurse, optometrist or physician’s assistant MUST complete Part 2. If you are also
applying for meter-exempt parking, your physician, advanced practice nurse or physician’s assistant must also complete
Part 3.
PART 1: Applicant Information
I hereby certify that I meet the definition of a person with a disability as provided in 625 ILCS 5/1-159.1, and I certify that my physical
condition entitles me to the issuance of a Persons with Disabilities Parking Placard/License Plates. By affixing my signature below, I
understand that the parking placard/license plates may not be used unless I am the driver or passenger of the vehicle.
WARNING: Misuse of a parking placard/plates or making a false application may result in revocation of your
placard/plates, a 12-month suspension or revocation of your driver’s license and a fine of up to $1,000.
_________________________________________________________________________________________________
Name of Person with Disability
Male/Female
Date of Birth
_________________________________________________________________________________________________
Address
City, State, ZIP
_________________________________________________________________________________________________
Daytime Telephone Number
Disability Parking Placard # (if any)
Disability Plate # (if any)
Today’s Date
_________________________________________________________________________________________________
Signature of Person with Disability
Illinois Driver’s License or Illinois ID Card # of Person with Disability
_________________________________________________________________________________________________
PART 2: Medical Eligibility Standards and Medical Professional Certification
As a licensed physician, advanced practice nurse, optometrist or physician’s assistant, I certify that the individual named in Part 1 has
a condition that constitutes him/her as a person with disabilities as defined in statute due to a service connected diagnosis of: ___
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Check all that apply:
____ Patient is restricted by a lung disease to such a degree that the person’s forced (respiratory) expiratory volume (FEV) is one
second, when measured by spirometry, is less than one liter.
____ Patient uses a portable oxygen device.
____ Patient has a Class III or Class IV cardiac condition according to the standards set by the American Heart Association.
____ Patient cannot walk without the assistance of a wheelchair, walker, crutch, brace, and other prosthetic device or without the
assistance of another person.
____ Patient is severely limited in the ability to walk due to an arthritic, neurological, oncological or orthopedic condition.
____ Patient cannot walk 200 feet without stopping to rest because of one of the above five conditions.
____ Patient is missing a hand or arm or has permanently lost the use of a hand or arm.
LENGTH OF DISABILITY:
Disability is permanent
As the medical professional(s) executing this document and verifying the nature of the applicant’s disability, I understand
that making a false representation of a person’s disability for the purposes of obtaining any type of disabled parking plac-
ard or plates may result in a suspension or revocation of my driver’s license and a fine of up to $1,000.
_________________________________________________________________________________________________
Medical Professional’s Printed Name
Specialty
Office Telephone Number
_________________________________________________________________________________________________
Address
City, State, ZIP
_________________________________________________________________________________________________
Medical Professional’s Signature
IL License Number
Today’s Date
____________________________________________________________________
__________________________________
Name of Collaborating/Supervising Physician (if signed above by Advanced Practice Nurse
Supervising Physician State Medical License #
or Physician’s Assistant)
Printed by authority of the State of Illinois. March 2015 — 1 — VSD 800.2
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