Fillable Printable Form MV-664.1MP - Application for a Metered Parking Waiver - New York

Form MV-664.1MP - Application for a Metered Parking Waiver - New York

MV-664MP No. Issued: __________________ Date Issued:_______________ MV-664 No. Issued: ____________________

F Part A

l Uses portable oxygen

l Legally blind

l Limited or no use of one or both legs

l Unable to walk 200 ft. without stopping

l Neuromuscular dysfunction that severely limits mobility

l Class III or IV cardiac condition. (American Heart Association standards)

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

l 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

l 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.

F Part B

Please certify that the severely disabled patient (as described in Part A) also has a severe disability

that limits one or more of the following (check all that apply):

o Fine motor control of both hands

o Ability to reach or access a parking meter due to use of a wheelchair or other ambulatory device

o Ability to reach a height of 42 inches from the ground due to lack of finger, hand, or upper extremity strength or

mobility.

APPLICATION FOR A METERED PARKING

WAIVER FOR PERSONS WITH SEVERE DISABILITIES

INFORMATION ABOUT PERSON WITH DISABILITY — (Please print, and sign by the arrow.)

Last Name

Address: No. and Street Apt. No.

Date of Birth

o Male

o Female

Driver License Number and Expiration Date: __________________________________________________________

Do you have license plates for persons with disabilities?

o No o Yes, plate number is:_____________________

Do you have a parking permit for persons with disabilities?

o No o Yes, permit number is:____________________

First

City

M.I.

State

Telephone No.

( )

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.

Instructions for completing this application are on page 2. Take the completed application to the issuing agent in the area where you

live. Please bring your New York State driver license with you when you apply for the waiver.

MV-664.1MP (4/15)

File Information (For Issuing Agent Use Only)

PAGE 1 OF 2

MEDICAL CERTIFICATION—This section must be completed only by a physician, physician assistant (PA), or doctor of

osteopathy (DO).

Physician/PA/DO Name (Print/Type)

Professional License No.

Physician/PA/DO Address (Print/Type)

Telephone No.

( )

(Date)

(Physician/PA/DO Signature)

By signing this form I certify that this severely disabled patient (as defined by NYS Vehicle and Traffic Law Section 404-a) has a

disability limiting one or more of the actions listed in Part B above. I understand that making a false statement or providing

misinformation on an application to obtain or facilitate the receipt of a metered parking waiver for people with disabilities may

result in a civil penalty ranging from $250-$1,000 and/or criminal prosecution and penalties.

The metered parking waiver is available to people who are severely disabled as defined in Vehicle and Traffic Law Section 404-a

(see Part A) AND

who also have a disability that hinders their ability to put payment into a parking meter (see Part B).

By signing this form I certify that I meet the requirements for a metered parking waiver. I understand that making a false statement

or providing misinformation on an application to obtain or facilitate the receipt of a metered parking waiver for people with

disabilities may result in a civil penalty ranging from $250-$1,000 and/or criminal prosecution and penalties.

STEP 1 - Metered Parking Waiver Requirements

STEP 3 - Have your doctor fill out the Medical Certification section.

STEP 2 - Complete the section “Information About Person with Disability”.

STEP 4 - Bring your completed application to the issuing agent in the area where you live to receive a waiver.

www.dmv.ny.gov

MV-664.1MP (4/15)

PAGE 2 OF 2

The metered parking waiver is intended for use by those individuals whose severe disabilities make it extremely difficult to put

payment into a parking meter when traveling alone. Any person who makes a false statement or gives information which is known to

be false to a public official to obtain a metered parking waiver may be subject to a civil penalty of $250-$1,000 and possible criminal

prosecution.

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR A METERED PARKING WAIVER

In order to be eligible for the metered parking waiver, you must meet all of the following conditions:

1. Be a resident of New York State; and

2. Be a resident of the city, town, or village in which you are obtaining the waiver; and

3. Hold a valid New York State driver license; and

4. Are severely disabled as defined in Vehicle and Traffic Law Section 404-a (see Part A on page 1); and

5. Your severe disability as certified by a licensed physician, physician assistant, or doctor of osteopathy limits one or more of

the following:

a. Fine motor control in both hands; or

b. Ability to reach or access a parking meter due to use of a wheelchair or other ambulatory device; or

c. Ability to reach a height of 42 inches from the ground due to lack of finger, hand or upper extremity strength or mobility.

Do you meet all

of the requirements listed above in 1-5?

If No, you are not

eligible for a metered parking waiver.

If Yes, continue on to Step 2.

• Clearly print your personal information in the boxes provided.

• Print your New York State driver license number and expiration date in the space provided. Your driver license number is

the 9 digit ID number located near your picture. The expiration date is printed in red on the bottom of the license. This

number needs to be a date in the future.

• If you have license plates with the International Symbol of Access, check “Yes” and write your plate number in the space

provided. If you do not have those plates, check “No”.

• If you have a permanent (blue) parking permit for people with severe disabilities, check “Yes” and write the permit number in

the space provided. The permit number is a 6 or 7 digit number printed in black along the top portion of the permit. If you do

not have a permanent permit, check “No”.

• Read the certification statement and sign the form in the space provided.

• Bring the application form to your physician, physician assistant(PA), or doctor of osteopathy(DO). This form can only be

filled out by a physician/PA/DO, not a nurse practitioner, chiropractor, or podiatrist.

• The physician/PA/DO should read Part A and read and fill out Part B by checking all of the disabilities that apply.

• The physician/PA/DO should print his or her name, license number, address and telephone number in the space provided.

• The physician/PA/DO must sign and date the form. (NOTE: Original signatures only.)

Issuing agents are often the town, village or city clerk or the local police department. You can not obtain a metered parking waiver

from any State or County Motor Vehicles office. Call your local city, town or village hall to find out where to apply for the waiver. If

you are a resident of Nassau County, call (516) 227-7399 to find out where to apply.