Free 42070.FH11 - Indiana

APPLICATION FOR DISABILITY PARKING PLACARD OR DISABILITY PLATE
State Form 42070 (R6 / 7-07)

INDIANA BUREAU OF MOTOR VEHICLES The information in this document is confidential according to IC 9-14-5. * Your Social Security number is being requested by this state agency in accordance with IC 4-1-8-1. Disclosure is voluntary and you will not be penalized for refusal. INSTRUCTIONS: Please print or type APPLICANT INFORMATION
Name of applicant (first, last, middle initial) (if corporation or agency, list name) Address (number and street, city, state and ZIP code) Social Security number * Federal Identification number Date of birth (month, day, year)

SECTION 1 - APPLICATION FOR DISABILITY PLATE (You must present this form at a License Branch within your county of residence to receive a Disability Plate) A. I am qualified to receive a Disability Plate because (check one): 1. I have permanent disability that requires the use of a wheelchair, walker, braces or crutches. 2. I have permanently lost the use of one or both legs. 3. My mobility is permanently restricted due to a pulmonary or cardiovascular disability, arthritic condition, orthopedic condition or neurological impairment. This requires the completion of SECTION 3A - "Practitioner's Certification" on the bottom of this form (a separate attachment is not acceptable). I am permanently blind or visually impaired as defined by IC 12-7-2-21 or 12-7-2-198. This requires the completion of SECTION 3B - "Practitioner's Certification" on the bottom of this form by an optometrist or ophthalmologist (a separate attachment is not acceptable). I have been issued a permanent parking placard under IC 9-14-5. FOR BRANCH USE ONLY
Plate number

4. 5.

I affirm under the penalties of perjury that the foregoing representations are true (parent or legal guardian must sign for persons under the age of sixteen).
Signature Date (month, day, year)

NOTE: A person who knowingly and falsely represents himself as having the qualification to obtain a disability placard commits a Class C misdemeanor pursuant to IC 9-18-22-6.

B. If plate is issued to person other than the disabled person then the recipient of the plate must complete the following:
Name of applicant (first, last, middle initial) Address (number and street, city, state and ZIP code) Social Security number *

I affirm under the penalties of perjury that the vehicle to be registered with the plate applied for on this form is used regularly to transport the person qualifying herself / himself as disabled on this form.
Signature Date (month, day, year)

SECTION 2 - APPLICATION FOR DISABILITY PARKING PLACARD (You must present this form at any Indiana License Branch to obtain a Disability Parking Placard.) A. I am: (check one) 1. Applying for a new Disability Placard 3. Applying for a duplicate Disability Placard 2. 4. Renewing my Disability Placard Applying for an additional Disability Placard

B. I am qualified to receive a Disability Placard because (check one): 1. I have a disability that requires the use of a wheelchair, walker, braces or crutches. 2. 3. a. Temporarily b. Permanently I have lost the use of one or both legs. a. Temporarily b. Permanently My mobility is restricted due to a pulmonary or cardiovascular disability, arthritic condition, orthopedic condition or neurological impairment. (This requires the completion of SECTION 3A of the Practitioner's Certification on the back of this form. A separate attachment is not acceptable.) a. Temporarily b. Permanently SECTION 2B continued on the reverse side of this form.

SECTION 2 - CONTINUED B. I am qualified to receive a Disability Placard because (check one): 4. I am permanently blind or visually impaired as defined by IC 12-7-2-21 or 12-7-2-198. (This requires the completion of SECTION 3B of the 5. 6. Practitioner's Certification below by an optometrist or ophthalmologist. A separate attachment is not acceptable.) the above-named corporation, partnership or unincorporated association operates programs (including the provision of transportation), or facilities for persons with disabilities and is empowered by the State of Indiana or its political subdivision to do so. of a government entity / government contract. Beginning date (month, day, year) Ending date (month, day, year)

I affirm under the penalties of perjury that the foregoing representations are true (parent or legal guardian must sign for persons under the age of sixteen).
Signature Date (month, day, year)

NOTE: A person who knowingly and falsely represents himself as having the qualification to obtain a disability placard commits a Class C misdemeanor pursuant to IC 9-14-5-9.

SECTION 3 - PRACTITIONER'S CERTIFICATION Please complete Section 3A or 3B and sign in Section 3C. Applicant is responsible for any costs associated with completion of certification. SECTION 3A - PHYSICIAN'S AND CHIROPRACTOR'S CERTIFICATION A. I certify that __________________________________ is severely restricted in mobility due to a pulmonary or cardiovascular disability, arthritic condition, orthopedic condition or neurological impairment. This severe restriction in mobility is (check one) permanent temporary and is expected to end on__________________ 20 _____ . (NOTE: The expected date must be filled in for temporary disabilities.) B. I am (check one and sign Section 3C): 1. A physician having an unlimited license to practice medicine in Indiana. A physician who is a commissioned medical officer of the armed forces of the United States or the United States Public Health Service. 3. 4. 5. 6. An advanced practice nurse licensed under IC 25-23. A chiropractor licensed under IC 25-10-1. A podiatrist licensed under IC 25-29-1. A physician who is a medical officer of the Veterans Administration of the United States.

2.

SECTION 3B - OPHTHALMOLOGIST'S AND OPTOMETRIST'S CERTIFICATION A. I certify that __________________________________ is permanently blind or visually impaired as defined by IC 12-7-2-21 or 12-7-2-198. B. I am (check one and sign Section 3C): 1. An ophthalmologist licensed to practice in Indiana. SECTION 3C - PRACTITIONER'S SIGNATURE
Signature of practitioner Printed name (first, last, middle initial) Address (number and street, city, state and ZIP code) Telephone number License number Date (month, day, year)

2.

An optometrist licensed to practice in Indiana.

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) FOR BRANCH USE ONLY PLACARD NUMBER(S)

1 2 3 4 5
Date of application (month, day, year) Date of application (month, day, year)