Fillable APPLICATION FOR DISABLED PERSON LICENSE PLATE, PLACARD AND/OR

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APPLICATION FOR DISABLED PERSON LICENSE PLATE, PLACARD AND/OR

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To obtain a disabled person license plate, complete Section A, B, C, D & E
To obtain a disabled person decal, complete Section A, B, C, D & E
This form must be completed in the name of the applicant. Please complete all information, sign and submit the form in person or by mail to
your local County Clerk’s office. Go to tn.gov/revenue for your local county clerk contact information.
A. FEES: Please make your selection(s) below. State fees are indicated below.
Additional County Clerk fees may apply. Contact your local County Clerk for more information.
B. Complete the information below:
_______________________________________________________________________________________________________
FIRST NAME MIDDLE NAME LAST NAME DATE OF BIRTH: MONTH DAY YEAR
_______________________________________________________________________________________________________
STREET ADDRESS CITY OR TOWN COUNTY STATE ZIP
C. Complete the information below, only if requesting a disabled person license plate or decal: Please provide the
description information for the vehicle to which plate or decal will be affixed, below.
If your application is only for a placard, it is not necessary to complete this portion.
______________________________________________________________________________________
TITLE NUMBER PLATE NUMBER VEHICLE IDENTIFICATION NUMBER
D. Applicant Certification Statement: I, the undersigned applicant, hereby certify, under the penalties prescribed in Tenn. Code
Ann. 55-21-108 and/or 55-21-103, that the statements made herein are true and correct to the best of my knowledge, information and
belief.
Applicant's Signature: ______________________________________________________Date: ____________________________
For applicants who are a parent or legal guardian of a permanently disabled individual, please indicate the following and sign above:
Disabled person’s name: _________________________________ Applicant is this person’s (check one): □ Parent □ Legal Guardian
RV-F1310301 (Rev. 7-17)
$ 26.50
No Charge
$ 3.00
Placard for Persons with Permanent Disabilities*
Permanent Disability Placard (with no vehicle registration in applicant’s name)
Permanent Disability Placard (with vehicle registration in applicant’s name)
Permanent Disability Placard Renewal (with or without registration in applicant’s name)
Permanent Disability Placard (replacement fee)
$
2.00
*
Please note the Permanent Disability Placard expires 2 years after issuance. To renew, please submit application with the appropriate renewal fees.
Placard for Persons with Temporary Disabilities
Temporary Disability Placard (valid for 6 months)
$ 10.00
Temporary Disability Placard Renewal (Must submit new application. Renewal must run consecutively for the same disability)
$ 10.00
$2
6.50
No Charge
Disabled Person License Plate/Decal
Disabled Person License Plate
Disabled Person License Plate (Confined to a wheelchair)
Disabled Driver Decal
No Charge
APPLICATION FOR DISABLED PERSON LICENSE PLATE, PLACARD AND/OR DECAL
To obtain a disabled person parking placard, complete Section A, B, D & E
Hearing Impaired Decal
First Decal
Second Decal
No Charge
$ 5.00
Reference Material
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APPLICATION FOR DISABLED PERSON LICENSE PLATE, PLACARD AND/OR DECAL
CERTIFICATION OF DISABILITY
E. Certification of Disability: The section below must be completed by a medical doctor licensed to practice medicine, a
Christian Science Practitioner listed in the Christian Science Journal, nurse practitioner (APRN), or physician's assistant (PA).
NOTE: This is not required when renewing a permanent disability placard or disabled person license plate, but is required each
time a temporary disability placard is requested.
Mechanical device used: Crutches Braces Other (list)____________________________________
Is applicant PERMANENTLY confined to a wheelchair? Yes No
The nature of the disability is ________________________________________________________________________
Is disability permanent ___________ or temporary _____________?
Name of Doctor/Christian Science Practitioner/APRN/PA______________________________________________________
Address:_________________________City:________________ State: Zip Code: Telephone No: ___________
In accordance with Tenn. Code Ann. 55-21-103 and 55-21-152, I hereby certify that the disabled individual named in this application has
appeared before me and that, in my opinion, he or she meets the requirements of Tenn. Code Ann. 55-21-102(3)(A), (B), and (C) or 55-
21-102(4).
Signature of Doctor/Christian Science Practitioner/APRN/PA: ________________________________Date:_______________
COUNTY CLERK USE ONLY
_____________ ___________________ _________________________ _______________
Approved By Date Approved Placard/Plate/Decal Number Assigned Placard Expiration
Date
PAGE 2
Is applicant hearing impaired? Yes
No
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REFERENCE MATERIALS FOR DISABLED PERSON LICENSE PLATE/PLACARD/DECAL APPLICATION
Tennessee Code Annotated Sections 55-21-101 through 55-21-152
(1) A disabled person is:
one who is disabled by paraplegia, amputation of leg, foot or both hands, or other condition, certified by a physician duly
licensed to practice medicine (or APRN/PA), resulting in an equal degree of disability (specifying the particular condition)
so as not to be able to get about without great difficulty, including impairments that, regardless of cause or
manifestation, confine such person to a wheelchair or cause such person to be so ambulatory disabled that he or she
cannot walk two hundred feet (200’) without stopping to rest and includes, but is not limited to, those persons using
braces or crutches, arthritics, spastics and those with pulmonary or cardiac ills who may be semi-ambulatory;”
the owner of a motor vehicle with vision of not more than 20/200 with correcting glasses.
the owner of a motor vehicle who is so ambulatory disabled that he or she cannot walk two hundred feet (200’) without
stopping to rest and who is seeking treatment and/or healing solely by prayer through spiritual means in the practice of
religion in accordance with the creeds or tenets of the First Church of Christ, Scientist in Boston, Massachusetts. Such
condition shall be certified by a Christian Science practitioner listed in The Christian Science Journal as resulting in a
degree of disability so that such person is not able to get about without great difficulty;”
(2) One (1) registration and license plate shall be provided free to those disabled persons that are permanently and totally confined to
a wheelchair, when so certified by a physician’s statement.
(3) Any owner or lessee of a motor vehicle who is permanently disabled as certified by a physician licensed to practice medicine, a
physician’s assistant or nurse practitioner acting in conjunction with a written protocol developed jointly by a physician, or a
Christian Science practitioner OR any owner or lessee of a motor vehicle who is the parent or legal guardian of a person who is
permanently disabled and who is incapable of operating a motor vehicle, qualifies for a disabled person license plate.
(4) Permanent and temporary placards shall be issued by the local county clerks.
(5) Permanent placards
may be issued to persons who are permanently disabled as noted on the physician’s statement;
may be issued to the parent or legal guardian of a permanently disabled individual;
shall cost the same as the regular fee for passenger motor vehicles;
shall expire two (2) years from the date issued.
(6) Temporary placards
may be issued to persons who are temporarily disabled by a non-ambulatory or semi-ambulatory condition due to
surgery, bone fracture or breakage, or similar condition, and whose temporary disabling condition and the estimated
duration of such condition is noted on the physician’s statement;
shall cost $10.00 for the initial placard issuance and subsequent renewals;
shall be issued for the estimated duration of the condition, but not in excess of six (6) months;
the use of a “prescription pad” statement can also be used as evidence to determine eligibility for a temporary placard if
it is attached to form RV-F1310301 and describes the mobility disabilities as “non-ambulatory” or “semi-ambulatory”.
(7)
Disabled Driver Decals:
may be issued to allow holders of new specialty earmarked license plates to keep their specialty plate but take advantage
NOTE: An affidavit must accompany this application when replacing a lost or stolen placard. If the placard is mutilated, the
remaining portion of the placard must also accompany the application.
(8)
of the disabled parking privileges.
Hearing Impaired Decals:
may be issued to persons who are hearing impaired as indicated by a physician's statement;
•
shall be placed in the upper corner of the driver's side of the front windshield, and should be removed when the applicant
transfers the vehicle. If the used decal is presented to the Department, a new decal shall be issued without cost.
•
one (1) decal shall be provided free; a second (2nd) decal costs $5.00;
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APPLICATION FOR DISABLED PERSON LICENSE PLATE, PLACARD ANDOR

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Completed 18 July 2020

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