Fillable Printable Application for Disability Parking Certificate - Minnesota

Application for Disability Parking Certificate - Minnesota

Minnesota Dep artment of Publ ic Safety

Driver and Vehicle Services Division

445 Minnes ota St., Suite 164

St. Paul, MN 55101-5164

Internet: MNdriveinfo.org

FOR CENTRAL OFFICE USE

APPLICATION FOR DISABILITY PARKING CERTIFICATE PS2005-28

DISABLED INDIVIDUAL SECTION

To be com

leted b

or for the

erson with a certifiable disabilit

Full Name (Please Print) Last, First and Middle Date of Birth

Address

City State Zip Code

Are you a licensed driver? Yes No

Do you have a Minnesota ID Card?

Yes No

License/ID Number

Have you ever had a Minneso ta Disability Parking Certificat e? Yes No MN disability license plates? Yes No

List certificate and/or plate #______ __________ __________

If applying for duplicate, check reason:

Lost Stolen Damaged Other; Please Explain

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Check Here if this applicati on is for two disability certificates Check Here if this application is for a second disability certificate

(Not available if you have disability license plates) (Limit of 2 certificates per person)

I hereby certif y the above information is complete a nd accurate to the best of my knowledge. I also give permission to my physician to

supply the information requested.

Date_____ ___________ ______ Signature_________________________________________________________ ____

Medical Section: The applicant must meet one or more of the definition(s) of a “physically disabled person ” described below

• Items six through ten must specifically identify the disability or the application will be delayed or denied.

Generic terms such as “Back Pain”, “Leg Pain”, etc. are not acceptable.

The Applicant:

1. Has a cardiac condition to the extent that the applicant’s functional limitations are classified in severity as Class III or

Class IV according to the standards set by the American Heart Association.

2. Uses portable oxygen.

3. Has an arterial oxygen tension (PAO

) of less than 60 mm/Hg on room air at rest.

4. Is restricted by a respiratory disease to such an extent that the applicant’s forced (respiratory) expiratory volume for one second, when

measured by spirometry, is less than one liter.

5. Has lost an arm or leg and does not have or cannot use an artificial limb.

6. Due to disability, uses a wheelchair or cannot walk without the aid of:

Another Person; A Walker; A Cane; Crutches; Braces; A Prosthetic Device: Please specify______________________________

or other Assistive Device: Please specify___________________________________

7. Has a disability that would be aggravated by walking 200 feet under normal environ mental conditions to an extent that would be life-threatening.

This condition is :________________________________________ _________ Must be Specific Physical Disability

8. Due to disability cannot walk 200 feet without stopping to rest.

This condition is:___________________________________________________ Must be Specific Physical Disability

9. Due to disability cannot walk without a significant risk of falling.

This condition is:____________________________________________________ Must be Specific Physical Disability

10. Has a specific medical condition related to pregnancy that could be aggravated by walking to the extent that the life or health of the person or

fetus may be endangered (Temporary certificate only; may not exceed expected length of pregnancy)

Describe Condition:

Certificate Type:

Fee $5.00 ea. Temporary 1 t o 6 Months Must Specify →

Fee $5.00 ea. Short Term 7 to 12 Months Must Specify →

No Fee

Long-Term 13 to 71 months Must Specify →

No Fee

6-year Certificate For permanent disabilitie s

Is the applicant qualified, in all medica l respects to exercise reasonable and ordinary control over a motor vehicle?

Yes Yes, with adaptive equipment No, pleas e specify

A no answer may result in cancellation of driving privilege.

Failure to answer this question will result in a request for a medical report.

I certify, by my sign ature as a licensed physician, reg. physician’s assistant, adva nced prac tice registered nurse, or chiropractor that, in my

professional opinion

(Patient’s name) meets the definition(s) I ha ve checked ab ove and is entitled to the

applied for parking certificate. I would be guilty of a misdem eanor and subject to a fine of $500.00 for fra udulently certifyi ng the applicant.

Signature & Title Date Print Name

Telephone Number

( )

Address, City, State, Zip Code

Deputy Stamp

Certificate Expiration Date

Requested

Month Year

IMPORTANT!

If no date is indicated

the certificate will be

issued for the minimum

duration of certificate

type

NOTICE: Any information suppli ed on this form is collecte d under the authority of Minnesota Statutes, and will be used only by auth orized Driver

and Vehicle Services Division personnel to determine your eligibility for the issuance of a Disability Parking Certificate and driving privileges.

Failure to provide and return the requeste d data will result in the denial of your request.

Please read and familiarize yourself with the information on this form.

WHO IS ELIGIBLE FOR THE CERTIFICATE?

Any Minnesota resident who meets one or more of the definitions of a “physically disable d perso n” listed on the front of this application.

Residents of other states that are visiting or temporarily residing in Minnesota may apply for a Temporary certificate (6 months maximum).

Residents of ot her states must make applicat ion for permanent certificates in their home state.

HOW DO I USE THE CERTIFICATE?

The certificate is issued to you, not the vehicle. Therefore, you may display it when parking any vehicle you are driving or riding in. The

certificate is to be displ ayed on the re ar view mirror onl y wh en parked. Dri ving with the cert ificate hanging from the m irror creates an obstructed

view, which is i llegal and ver y dangerous. If your d isability makes it impra ctical to hang the certificate from the re ar view mirror it may be placed

on the dashbo ard when parked.

Only one certificate is issued per disabled individual if applicant also possesses a set of disability license plates. You may qualify for 2

certificates if you do not have disability license plates for your vehicle. Certificates are valid until the last day of the month indicated on the

certificate.

I HAVE HEARD THAT SOME PEOPLE WHO HAVE APPLIED FOR THE CERTIFICATE HAVE BEEN REQUIRED TO RETEST FOR THEIR

DRIVER LICENSE. IS THAT TRUE?

YES. If a disabled pers on with a driver’s license applies for a certificate, the Department of Public Safety may check the driver’s lic ense record.

If the department has a record of the disabilit y, there is no action taken. If the department has no such record of the disability, certification must

be made that the disability will not interfere with his/her driving ability. In most cases, the department will ask the applicant to come in for an

interview so they can determine if a re-test may be necessary. Although this procedure may be an inconvenience for some, the Department of

Public Safet y has an obligation to ensure tha t licensed drivers are qualifie d to operate a motor vehicle.

WHAT PRIVILEGES DOES THE CERTIFICATE PROVIDE IN MINNESOTA?

A vehicle that prominently displays the certificate may be parked by or solely for the benefit of a physically disabled person

1) in a designated

disability parking space; 2) in a non-restricted metered parking space without obligation to pay the meter fee, and without regard to time

limitation unless otherwise posted; or 3) in a non-metered time limited passenger vehicle space u nl ess otherwise posted.

When parked the occupants must exit the vehicle. It is not permissible to use the certificate to wait in a disability parking space.

This la w does not permit parking in areas prohibited by Sections 169.32 and 169.34, 1) in designated no parking spaces; 2) in parking spac es

reserved for specified purpose; 3) where there is a loc al ordinance that prohibits parking on any street or highway for the purpose of creating a

Fire lane; or 4) to provide for the accommo dation of heav y traffic during morning and afternoon rush hours.

For privileges in other states or Can adian provinces, please contact those states/provinces.

MISUSE OF THE CERTIFICATES

Any unauthorized use or reproduction of the Department issued Disability Parking Certificate is subject to the revocation of parking privilege. A

person who is convicted of misusing the certificate would be guilty of a misdemeanor and subject to a fine of $500.00. Knowingly allowing the

misuse of the certificate or disability license plates shall result in the cancell ation of disability parking pr ivileges.

WHAT IF I MISPLACE/LOSE MY CERTIFICATE?

If you need a replacement certificate you must apply for a duplicat e certificate you may co mplete Section A of this application.

For replacement of Temporary and Short-Term Certificates due to loss or theft there is a fee of $5.00.

The certificate is valid for the d uratio n of the p erson ’s disabilit y, as specified b y the health care provider’s statement.

1 to 6 m onths for a temporary certificate, 7 to 12 months for a short-term certificate, 13 to 71 months for a long-term cer t ificate, or six yea rs for a

permanent disabil ity. The disability may need to be re-certified before a new or subsequent certificate can be issued.

If your health care provider extends the length of the disability there is no fee for the subsequent certificate, however along with the health care

provider’s signature the medical statement is required and must clearly state that it is an extension for a previously certified disability

For a lost certificate you may be required to identify measures that you have taken in order to prevent future lost certific ates.

For stolen certificates, you may be asked to provide a copy of the police report regarding the theft.

If you have further questions regarding this application, contact the Driver and Vehicle Services Division at (651) 297-3377. If you have

questions rega rding other services provided by Driver and Vehicle Services, pleas e call (651) 296-6911, or TT Y (651) 282-6555.

You may also contact us thro ugh the Internet at:

MNdriveinfo.org

This ap plication may be submitted at any mo tor vehicle office in Minnesota or by mail to the add ress listed on the front.

If relevant information is missing the application will be rejected.

The information provided by the applicant and health care provider is required by state and federal guidelines.

All data collect ed on a disabili ty certificate application is req uire d by law. This data is use d to determin e eligibilit y for issuance of a disabilit y

certificate. All data collected is private and may not be issued to anyone except law enforceme nt personnel (name/address information only) or

the applic ant.