Fillable Printable Form MV-400PH - Request for Custom Empire Plates - New York

Form MV-400PH - Request for Custom Empire Plates - New York

New York State Department of Motor Vehicles

REQUEST FOR CUSTOM EMPIRE PLATES - DISABLED REGISTRANT

INFORMATION AND INSTRUCTIONS:

Custom Empire license plates with a combination of two to six letters and/or numbers, followed by the International Symbol of Access, are available

to qualified disabled individuals. See Part 2 below for a description of qualifying disabilities. These custom plates are available only for vehicles that

use passenger plates and for vans and pick-up trucks registered by disabled persons, and may not be used for commercial purposes. The initial fee

for these plates is $60.00. There is a $31.25 annual renewal fee for these plates in addition to your regular vehicle registration renewal fee. You will

be billed $62.50 (two $31.25 annual renewal fees) for your custom plates every two years when you renew your registration.

To obtain these plates:

1. Verify that the vehicle on which the plates will be used is registered in the name of the person with the disability.

2. Fill out Part 1 below and have the appropriate medical professional complete the medical certification in Part 2.

NOTE: A medical certification is not required if you already have plates for the disabled and want to exchange them for custom plates

for the disabled. If you currently have plates for the disabled, check the appropriate box in Part 1 and provide your plate number so

Custom Plates Unit staff can verify your registration.

3. Complete Part 3 indicating the method of payment you will be using.

4. Follow the instructions in Part 4 for choosing a letter and/or number combination. You may submit up to three possible choices.

For each possible choice you must explain the meaning of your letter/number combination.

5. Mail your completed application and payment to:

DEPARTMENT OF MOTOR VEHICLES

CUSTOM PLATES UNIT

PO BOX 2775

ALBANY, NEW YORK 12220-0775

MV-400PH (4/11)

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Current License Plate Number _______________________

o Uses portable oxygen o Legally blind o Limited or no use of one or both legs o Unable to walk 200 ft. without stopping

o Neuromuscular dysfunction that severely limits mobility o Class III or IV cardiac condition. (American Heart Assoc. standards)

o Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition.

o Restricted by lung disease to such an extent that 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 of room air at rest.

o Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability, and which

imposes unusual hardship in the use of public transportation and prevents the person from getting around without great difficulty.

EXPLAIN HOW THIS DISABILITY LIMITS FUNCTIONAL MOBILITY.

____________________________________________________________________________________________________________

o PERMANENT DISABILITY: A “severely disabled” person is any person with one or more of the PERMANENT impairments,

disabilities or conditions listed below which limit mobility.

Diagnosis:____________________________________________________ Please check the conditions that apply:

INFORMATION ABOUT PERSON WITH DISABILITY AND VEHICLE TO BE REGISTERED —

(Please print, and sign by the arrow.)

Last Name

See Note on Page 3

Address: No. and Street

Apt. No.

Date of Birth

/ /

Please check here if you already

have plates for the disabled

First

City

M.I.

State

Daytime Phone (include area code)

( )

Current Plate No. Expiration Date

/ /

Zip Code

(Signature of Person with Disability or Signature of Parent or Guardian) — If signed by a parent or guardian,

please state your relationship to the person with the disability after your signature.

Check the box(es) that describe the disability, and fill in the diagnosis:

MD/DO/DPM/NP/PA Name

Professional License No.

MD/DO/DPM/NP/PA Address

Telephone No.

( )

(Date)

(MD/DO/DPM/NP/PA Signature)

PART 1

MEDICAL CERTIFICATION—This section must be completed only by a Medical Doctor (MD), Doctor of Osteopathy (DO),

Doctor of Podiatric Medicine (DPM), Nurse Practitioner (NP), or Physician Assistant (PA).

PART 2

Second Choice:

JOE

ORDER OF PREFERENCE (use letters and numbers only):

24563

Custom plates are manufactured in most combinations of as many as six letters and/or numbers on a first-come, first-

served basis. The plate number you request must include at least one letter. Each plate will have a reproduction of the

International Symbol of Access on the right side of the plate. You may include a State silhouette anywhere except at

the beginning of the plate number by placing the @ symbol in the box where you want the silhouette to appear. Also,

if you want a space between any letters/numbers, place a period (.) in the box(es) where you want a space.

u Letters (A thru Z) and numbers (0 thru 9) can be entered in a box.

u Other symbols, including dashes (-), may not be used. A period (.) in a box will be a blank space on the plate.

u To distinguish between the letter “O” and a zero, put a slash thru a zero (0). The slash will not appear on the plate.

u To distinguish between the letter “I” and the number “1”, use a capital “I”.

To request your custom plate numbers, fill in your choices in the boxed area below. Use the following guidelines:

In the “Choice” boxes below, write the combination of letters and numbers (not more than six) you want on your plate. You may select, in

order of preference, as many as three different combinations of letters and numbers. For each choice, enter each letter or number exactly as you

want it to appear on the plate. Place a period (.) in any box where you want there to be a space on the plate. Place the @ symbol where you

want a State silhouette to appear.

DO NOT WRITE IN THIS SPACE - FOR DMV USE ONLY

...............................................................................................................................................................................................

MV-400PH (4/11)

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EXAMPLE

In this example, your choice of plate numbers, in order of your preference, are: My Car (with the State silhouette), Joe and Joseph.

First Choice:

MY CAR

Third Choice:

JOSEPH

First Choice:

Second Choice: Third Choice:

Please Do Not Send Cash! If paying by check or money order, please make it payable to the “Commissioner of Motor Vehicles”.

Payment Method: o Check o Money Order o Master Card o Visa

o American Express o Discover

Name (as it appears on credit card) ______________________________________________________

Card Account Number ________________________________________________________ Expiration Date ________________________

Authorized Signature

ç ______________________________________________________________

If you have any questions, call (518) 402-4838 or visit us at: www.dmv.ny.gov

Amount Enclosed $ _______________________

REQUEST FOR CUSTOM EMPIRE PLATES FOR A DISABLED REGISTRANT

METHOD OF PAYMENT

PART 3

PART 4

You must explain the meaning of your letter/number combination. DMV reserves the right to reject, recall or cancel any plate that is

deemed objectionable. This includes plates that have already been issued.

1st Choice ________________________________________________________________________________________________

2nd Choice ________________________________________________________________________________________________

3rd Choice ________________________________________________________________________________________________

REQUIRED

It is important for you to know that making a false statement, or providing misinformation on an application to obtain or facilitate the

receipt of license plates for persons with severe disabilities is subject to fines ranging from $250 to $1,000 under Section 1203-

a(4) of the NYS Vehicle and Traffic Law and is punishable as a misdemeanor under Section 210.45 of the NYS Penal Law.

Customers

Requesting License Plates for Persons with a Disability

By signing Part 1 of this application, you are certifying:

l that the information you provide on this application is true;

l that you have read and understand the “Conditions for Using License Plates for Persons with Severe Disabilities” stated

below; and

l that you agree to comply with those conditions.

Medical Professionals

Providing Medical Information in Support of an Application for License Plates for

Persons with Severe Disabilities

By signing Part 2 of this application, you are certifying:

l that the medical information you are providing is true and complete; and

l that, in your opinion, the person named in Part 1 of the application is medically qualified to receive license plates for

persons with severe disabilities, according to the medical criteria specified in Part 2.

u The plates may be used to park in reserved parking spaces only when the person with the disability is driving or

riding in the vehicle. People who are not disabled cannot use your plates to park in a reserved space. Persons parking

illegally in these spaces violate Section 1203-c(4) of the NYS Vehicle and Traffic Law and can be fined $50 to $75 for a first

offense, and $75 to $150 for a second offense within two years. Municipalities can impose higher fines. Any person who abuses

any privilege, benefit, precedence or consideration arising from possession of the license plates, may have them revoked.

u The plates are valid everywhere in New York State where parking spaces are reserved for persons with disabilities. However,

use of the plates does not exempt you from state or local parking regulations or fees. They are also valid in most other states,

territories and foreign countries. If you are traveling outside of New York, check with the police or Motor Vehicles agency

where you are traveling, to be sure your plate will be accepted.

u Parking spaces reserved for people with severe disabilities must be marked with conspicuous and permanently installed

above-grade signs displaying the wheelchair symbol. These signs are positioned at a height of five to seven feet above the

parking space surface. Designation of reserved spaces may include the use of blue painted lines or markings. Do not park in

the striped access aisle next to spaces reserved for people with severe disabilities even if you have plates.

Access aisles provide room for people with wheelchairs and other specially equipped vehicles to transfer safely to and from

their vehicles.

u Localities designate parking spaces for persons with severe disabilities by local law or ordinance. If you have a question about

parking for the disabled on a particular street, find out if it is a county, city, town, village or state road, and contact the

authorities responsible for maintaining the road. If you have a question about reserved parking at any facility with off-street

parking, contact the facility manager or the local building inspector.

u PARKING IN NEW YORK CITY

New York City does not

set aside reserved spaces on its streets for persons with severe disabilities. Such parking is only

available off-street, in parking lots for shopping centers/malls, office/apartment buildings and college campuses. You can use

the state plates to park in designated spaces in those off-street lots.

The NYC Department of Transportation also issues a City permit

(a rectangular dashboard permit) that allows persons with

severe disabilities to park at most curbsides on NYC streets. City permits are issued to New York City residents and to people

who work or attend school in NYC, and who have a permanent disability that so severely affects their ability to walk that they

require the use of a private automobile. The New York City parking permit is not valid for parking outside of NYC

. To obtain

an application for a NYC permit, call (718) 433-3100.

NOTE TO CUSTOMERS AND MEDICAL PROFESSIONALS

USING LICENSE PLATES FOR PERSONS WITH SEVERE DISABILITIES

MV-400PH (4/11)

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