Free Utah Disabled Person And Physician Disability Certification, TC-842 - Utah

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Utah State Tax Commission
Division of Motor Vehicles, Salt Lake City, Utah 84134-8110

Disabled Person And Physician Disability Certification
IMPORTANT: Incomplete information will delay issuance of your windshield placard or disabled person license plates. Return this form to a Division of Motor Vehicles Office for processing.

TC-842 Rev. 1/06

Get forms online - tax.utah.gov

SECTION A. Physician Disability Certification For Individual Applicants (A separate certification or prescription is not acceptable)
Print name of Physician Physician's address, city, state, ZIP code Name of disabled person Check all the conditions listed below that apply to the applicant listed above Cannot walk two hundred feet without stopping to rest; Cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive devices; Is restricted by lung disease to such a degree that the person's forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixty mm/hg on room air at rest; Check whether conditions are permanent or temporary Permanent conditions Uses portable oxygen; Has a cardiac condition to the degree that the person's functional limitation is classified (according to American Heart Association standards) in severity as Class III or Class IV; and/or Is severely limited in their ability to walk due to an arthritic, neurological, or orthopedic conditions. Telephone number

(not to exceed Temporary conditions and expected to last until ____________________________ six months)

I certify that I am a licensed physician. I further certify that I have treated or I am familiar with the medical treatment provided to the person applying for the Disabled Special Group Plate and/or placard and that this persons condition is as stated in this section: Physician's signature X Physician license number Date signed

SECTION B. Disabled Person Care Facility Certification (Complete only if plates or placard are issued in the name of a business)
We certify that the business named on this form, is applying for disabled license plates and/or placards solely for the purpose of transporting disabled persons meeting the conditions explained in Section A while in our care. Date signed Signature Title X

SECTION C. Applicant Information
Applicant's name Street address or P.O. box number City/State/ZIP code Mailing address or P.O. box number (if different from above) City/State/ZIP code I hereby authorize my physician to release information pertaining to my disability, or the disability of the person named above. To the best of my knowledge the information on this form is true and correct. In the event the plate/placard is no longer needed to transport the disabled person during the registration period, the plate/placard will be surrendered to the Utah State Tax Commission. Date signed Applicant's signature X Daytime telephone no. Disabled person license plates Plate $15 fee (may also receive one permanent placard - no fee) Windshield placard - no fee (may receive two placards if disabled license plates are not issued) Replacement for windshield placard - no fee Previous placard number(s):

Please make a copy for your records.

Utah State Tax Commission Division of Motor Vehicles Office Salt Lake City, Utah 84134-8110 (801) 297-7780 or 1-800-DMV-UTAH For hearing impaired call (801) 297-2020
If you need an accommodation under the Americans with Disabilities Act, contact the Tax Commission at (801) 297-3811 or Telecommunications Device for the Deaf (801) 297-2020. Please allow three working days for a response.

58 Federal Regulations 10329 - Persons with disabilities which limit or impair the ability to walk means persons who, as determined by a licensed physician: (1) Cannot walk two hundred feet without stopping to rest; or (2) Cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive devices; or (3) Are restricted by lung disease to such an extent that the person's forced (respiratory) expiratory volume for one second, when measured by spirolmetry, is less than one liter, or arterial oxygen tension is less than sixty mm/hg on room air at rest; or (4) Use portable oxygen; or (5) Have a cardiac condition to the extent that the person's functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association; or (6) Are severely limited in their ability to walk due to an arthritic, neurological or orthopedic condition. 41-1a-414 Parking privileges for persons with disabilities (Volunteers may enforce provisions). (1) Except in parking areas designated for emergency use, a person with a disability, qualifying under rules made in accordance with Section 41-1a-420, may park an appropriate marked vehicle for reasonable periods without charge in metered parking zones and restricted parking areas, in a manner that allows proper access to the vehicle by the person with a disability. (2) Only those vehicles carrying a person with a disability special group license plate, or temporary removable windshield placard or removable windshield placard and transporting a qualifying person with a disability may park in an accessible parking space that is clearly identified as reserved for use by the person with a disability. (3) This section applies to and may be enforced on public property and on private property that is used or intended for use by the public. (4) The parking privileges granted by this section also apply to vehicles displaying a person with a disability special group license plate, temporary removable windshield placard or removable windshield placard issued by another jurisdiction if displayed on a vehicle being used by a person with a disability. (5) (a) any law enforcement agency authorized to enforce parking laws in this state may appoint volunteers to issue citations for violations of Subsections (3) and (4) or of any municipal or county accessible parking privileges ordinance for persons with disabilities. (b) A volunteer appointed under this subsection must be at least 21 years of age. (c) The law enforcement agency appointing a volunteer may establish any other qualifications for the volunteer that the agency finds desirable. (d) A volunteer may not issue citations until the volunteer has received training from the appointed law enforcement agency. (e) A citation issued by a volunteer under this subsection has the same force and effect as a citation issued by a peace officer for the same offense. 41-1a-1306 Abuse of persons with disabilities parking privileges - Revocation of special plate or transferable ID card. (1) A person with a disability who abuses the rights and privileges conferred under Section 41-1a-414 or allows an individual who is not a person with a disability to use those parking privileges, may have his person with a disability special group license plates or temporary removable windshield placard, or removable windshield placard revoked by the Division. (2) A person who violates section 41-1a-414 shall pay a minimum fine of $125. 58-67-102(8) "PRACTICE OF MEDICINE" MEANS: (a) To diagnose, treat, correct, administer anesthesia, or prescribe for any human disease, ailment, injury, infirmity, deformity, pain or other condition, physical or mental, real or imaginary, or to attempt to do so by any means or instrumentality: (b) To maintain an office or place of business for the purpose of doing any of the acts described in subsection (a) whether or not for compensations; (c) To use, in the conduct of any occupation or profession pertaining to the diagnosis or treatment of human diseases or conditions in any printed material, stationery, letterhead, envelopes, signs, advertisements, the designation "doctor," "doctor of medicine," "physician," "surgeon," "physician and surgeon," "Dr.," "M.D." or any combination of these designations, unless the designation additionally contains the description of the branch of the healing arts for which the person has a license.