State Form 42070 - Application For Disability Plate Or Parking Placard
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APPLICATION FOR DISABILITY PLATE OR PARKING
Bureau of Motor Vehicles
PLACARD
Winchester Mail Processing Center
State Form 42070 (R13 / 11-13)
PO Box 100
Approved by State Board of Accounts, 2013
Winchester, IN 47394
INDIANA BUREAU OF MOTOR VEHICLES
* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8. Disclosure is voluntary and you will not be penalized for refusal.
INSTRUCTIONS:
1. Complete in blue or black ink or print form.
2. To apply for a disability license plate complete Sections 1 and 2.
3. To apply for a disability parking placard complete Sections 1 and 3. If applying by mail for a temporary disability placard, include
payment of $5.00 in the form of a check or money order.
4. Have your medical practitioner complete Section 4.
5. Practitioner’s certification is not required for permanent placards issued to corporations, limited liability companies, partnerships,
or unincorporated associations that provide transportation to individuals with disabilities or operates programs or facilities for such
individuals.
6. Applications may be mailed to the Winchester Mail Processing Center, P.O. Box 100, Winchester, IN 47394.
SECTION 1 - APPLICANT INFORMATION
Name of Applicant (first, middle, last) (if corporation or agency, list name)
Social Security Number* or Federal Identification Number
Date of Birth (mm/dd/yyyy)
Address (number and street)
City
State
ZIP Code
SECTION 2 - APPLICATION FOR DISABILITY LICENSE PLATE
I am eligible to receive a disability license plate because: (check one)
I meet the definition of “disabled” (to qualify for the license plate) as outlined by Indiana Code 9-18-22-1.
I am blind or visually impaired.
I represent a corporation, limited liability company, partnership, or unincorporated association that provides transportation for
individuals with disabilities or operates programs or facilities for such individuals.
The Indiana Bureau of Motor Vehicles has issued me a permanent parking placard.
I swear or affirm under the penalty of perjury that the information in this application is true and correct. It is a Class C
misdemeanor to knowingly make false representations to obtain a disability plate.
Signature
Printed Name
Date Signed (mm/dd/yyyy)
If the applicant is not the vehicle owner, the vehicle owner must complete the following section.
The applicant must complete section 1 and 2 above.
Name of Vehicle Owner (first, middle, last) (if corporation or agency, list name)
Social Security Number* or Federal Identification Number
Address (number and street)
City
State
ZIP Code
I swear or affirm under the penalty of perjury that my vehicle regularly transports the applicant.
Signature
Printed Name
Date Signed (mm/dd/yyyy)
SECTION 3 - APPLICATION FOR A DISABILITY PARKING PLACARD
I am applying for the following type of disability placard: (check one)
New
Renewal
Duplicate
The disability is:
Temporary
Permanent
I am eligible to receive a disability placard because: (check one)
I meet the definition of “disabled” (to qualify for the placard) as outlined by Indiana Code 9-14-5-1.
I am blind or visually impaired.
I represent a corporation, limited liability company, partnership, or unincorporated association that provides transportation for
individuals with disabilities or operates programs or facilities for such individuals.
I swear or affirm under the penalty of perjury that the information in this application is correct. It is a Class C misdemeanor to
knowingly make false representations to obtain a disability placard.
Signature
Printed Name
Date Signed (mm/dd/yyyy)
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