Fillable Printable Form 2769 - Application For Disabled Person Placard

Form 2769 - Application For Disabled Person Placard

Form

2769

Missouri Department of Revenue

Application for Disabled Person Placard

Mail to: Motor Vehicle Bureau

P.O. Box 598 Phone: (573) 526-3669

Jefferson City, MO 65105-0598

Visit http://dor.mo.gov/mvdl

for additional information.

Form 2769 (Revised 08-2015)

Notary Information - Required

for replacements only

Subscribed and sworn before me, this

day of year

State County (or City of St. Louis) My Commission Expires (MM/DD/YYYY)

Notary Public Signature

Notary Public Name (Typed or Printed)

Embosser or black ink rubber stamp seal

__ __/__ __/__ __ __ __

Previous Placard Number Expiration Date (MM/DD/YYYY) Date of Physician’s Statement (MM/DD/YYYY)

__ __ /__ __ /__ __ __ __ __ __ /__ __ /__ __ __ __

New Placard Number Expiration Date (MM/DD/YYYY) Approved By Fee

__ __ /__ __ /__ __ __ __

Office Use

Only

r Signature

r Fee

r Good Cause for Add’l Placard

r Notary (Replacement Only)

Signature of Applicant Telephone Number Date (MM/DD/YYYY)

(__ __ __)__ __ __-__ __ __ __ __ __/__ __/__ __ __ __

Any false statement is a violation of the law and may be punished by fine imprisonment, or both. Fraudulent application, renewal, issuance,

procurement, or use of disabled person license plates or windshield placards is a misdemeanor.

Signature

Mail To - If different

than above

Name Telephone Number

(__ __ __)__ __ __-__ __ __ __

Street Address City State Zip Code

Applicant Information

Legal Name of Disabled Person (Last, First, Middle) or Business

Driver License Number or Federal Employer Identification Number Date of Birth (MM/DD/YYYY) Gender

__ __/__ __/__ __ __ __

Street Address City State Zip Code

I hereby certify that I am

r A disabled person r The parent or guardian of a disabled person r A representative of an agency that transports disabled persons

r 75 years old or older and am not required to submit a physician’s statement at time of renewal

Select All

That Apply

Temporary r New-$2 r Renewal-$2 Permanent Placard r New r Renewal r Record r Name r Address

Placard

r Replacement-$4

(No Fee)

r Replacement

Change Only Change Change

Do You Currently Have Disabled If replacement placard is required, select one of the following (Notary Required):

License Plate(s)?

r Yes r No r Lost r Stolen r Mutilated r Destroyed r Never Received (Replace at no fee)

How many disabled placards do State reason additional disabled placard is needed if requesting more than one placard:

you currently have?

Validation

Reset Form

Print Form

Submit the following items:

1. This completed and signed application.

2. Physician’s Statement for Disabled Person Placard (Form 1776) Note: Any not-for-profit group, organization, or other

entity that transports physically disabled persons must submit a statement on business letterhead, signed by an officer

that states the entity transports physically disabled persons. The Physician’s Statement must be issued within 90 days

of the application date. The Physician’s Statement for Disabled Person Placard (Form 1776) is not required to obtain a

replacement placard. A Physician’s Statement is required every four years for renewal applicants under the age of 75.

3. A $2 fee for each temporary placard or $4 fee for each temporary replacement placard. (There is no fee for new, renewal,

or replacement permanent placards.)

You may submit the items above to your local license office or by mail to the following address.

Motor Vehicle Bureau

PO Box 598

Jefferson City MO 65105-0598

Upon approval of your application, you will receive a new placard and a validated registration receipt. Keep the registration

receipt with you when using the placard.

Requirements

Form 2769 (Revised 08-2015)

A permanent or temporary disabled person placard (placard) is a removable windshield placard that is to be hung from the

front, middle rearview mirror of a parked vehicle in order to park in disabled parking spaces. It is unlawful to hang the placard

from the rearview mirror when driving the vehicle. Designated disabled parking spaces may only be used and the placard only

displayed when a physically disabled person is the occupant of the motor vehicle when the vehicle is parked (or immediately

before it is parked) or when the vehicle is being used to pick up or drop off the physically disabled person who was issued

the placard. The driver or any occupant shall produce the validated receipt of this application and photo identification of the

disabled person for whom the placard was issued upon request from any law enforcement or peace officer. Failure to do so is

a class A misdemeanor. A placard is not transferable to another person. It is unlawful for the placard owner to loan the placard

to any person for any reason, even if that person is disabled.

Who qualifies for a permanent/temporary disabled person placard?

Any physically disabled person, parent or guardian of a physically disabled person, or a not-for-profit group or organization

that transports physically disabled persons.

What is the definition of “physically disabled?”

The term “physically disabled” means a blind person, as defined in Section 8.700, RSMo, or a person with medical

disabilities which prohibits, limits, or severely impairs one’s ability to walk, as determined by an advance practice registered

nurse, licensed physician, chiropractor, physician’s assistant, podiatrist, physical therapist, or optometrist as follows.

1. The person cannot walk 50 feet without stopping to rest due to a severe and disabling arthritic, neurological, orthopedic

condition, or other severe and disabling condition;

2. The person cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device,

wheelchair, or other assistive device;

3. The person is restricted by a respiratory or other disease to such an extent that the person’s forced respiratory volume

for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than 60 mm/hg

on room air at rest;

4. The person uses portable oxygen; or

5. The person has a cardiac condition to the extent that the person’s functional limitations are classified in severity as Class

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

A person’s age shall not be a factor in determining whether such person is physically disabled.

Who determines physical disability?

An advance practice registered nurse, licensed physician, chiropractor, physician’s assistant, podiatrist, physical therapist,

or optometrist must certify the person is permanently or temporarily “physically disabled” by completing a Physician’s

Statement for Disabled Person’s Placard (Form 1776) and indicating whether the disability is permanent or temporary.

What are the penalties for misuse, fraudulent application, renewal, procurement, or use of a permanent temporary disabled

person placard?

Fraudulent application, renewal, procurement, or use of a placard, or parking in a disabled parking space by a person not

physically disabled or transporting a physically disabled person is a misdemeanor.

Should the permanent or temporary disabled person placard be returned to the Department of Revenue if the placard owner

is deceased?

Yes, the personal representative of the deceased or the person who has possession of the placard must return the placard

to the Department of Revenue. Failure to return the placard is a misdemeanor.

Permanent and Temporary Disabled Person Placard Information