Fillable Certification Of Disability printable pdf download

VETERAN

VSA 54 (07/01/2015)

CERTIFICATION OF DISABILITY

Purpose:

Veterans use this form to certify to a qualifying disability and to apply for registration fee exemption and special

license plates.

Instructions:

Send the completed form for validation to Veterans Services Officer, 210 Franklin Road, S.W.

Roanoke, VA. 24011. Submit validated form and your registration application to DMV at the address above.

VETERAN APPLICANT INFORMATION

DISABLED VETERAN NAME

DMV CUSTOMER NUMBER

DEPARTMENT OF VETERANS AFFAIRS CLAIM NUMBER

CHECK THE APPROPRIATE BOX(ES) IF YOU ARE APPLYING FOR A LICENSE PLATE AND/OR PLACARD DISPLAYING

DISABLED

DISABLED PLACARD

THE INTERNATIONAL SYMBOL OF ACCESS (DISABLED SYMBOL). NOTE: MEDICAL CERTIFICATION IS REQUIRED

PLATE

(Permanent)

VETERANS ADMINISTRATION USE ONLY

This veteran is certified disabled as follows under provision of Virginia law.

Loss of sight, limb(s) or hand(s)

Loss of use of limb(s) or hand(s)

Permanently and totally disabled

Other service-connected disability

VETERANS SERVICES OFFICER NAME (print)

VETERANS SERVICE OFFICER SIGNATURE

PHYSICIAN / PHYSICIAN'S ASSISTANT / NURSE PRACTIONER USE ONLY

This certification may be completed and signed by a Veteran Services physician or the applicant's choice of physician, physician's assistant, nurse practitioner

Cannot walk 200 feet without stopping to rest.

Has been diagnosed with Alzheimer's disease or another form of dementia

Uses portable oxygen

Is legally blind or deaf.

Cannot walk without the use of or assistance from any of the following: another

Has been diagnosed with a mental or developmental amentia or delay that impairs

person, brace, cane, crutch, prosthetic device, wheelchair, or other assistive device.

judgment including, but not limited to, an autism spectrum disorder.

Has a cardiac condition to the extent that functional limitations are classified in

Is restricted by lung disease to such an extent that forced (respiratory) expiratory

severity as Class III or Class IV according to standards set by the American Heart

volume for one second, when measured by spirometry, is less than one liter, or the

Association.

arterial oxygen tension is less than 60 millimeters of mercury on room air at rest.

Is severely limited in ability to walk due to an arthritic, neurological or orthopedic

condition.

Other debilitating condition that limits or impairs the ability to walk. SPECIFY CONDITION (required)

Other condition that creates a safety concern while walking because of impaired judgement or other physical, developmental or mental limitation. SPECIFY CONDITION (required)

CHIROPRACTOR / PODIATRIST USE ONLY

This certification may be completed and signed by the applicant's choice of chiropractor or podiatrist.

Is severely limited in ability to walk due to an arthritic, neurological or orthopedic

Cannot walk 200 feet without stopping to rest.

condition.

Cannot walk without the use of or assistance from any of the following: another person, brace, cane, crutch, prosthetic device, wheelchair, or other assistive device.

Other debilitating condition that limits or impairs the ability to walk. SPECIFY CONDITION (required)

MEDICAL PROFESSIONAL CERTIFICATION STATEMENT

I certify and affirm that the veteran applicant identified above has a PERMANENT DISABILITY which limits or impairs his/her ability to walk due to the reason indicated above. I also

certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all

supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or

representation on this form is a criminal violation.

MEDICAL PROFFESSIONAL NAME (print)

MEDICAL LICENSE NUMBER

ISSUING STATE

EXPIRATION DATE (mm/dd/yyy)

MEDICAL PROFESSIONAL SIGNATURE

DATE (mm/dd/yyyy)

OFFICE TELEPHONE NUMBER OFFICE FAX NUMBER

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