VSA 54 (07/01/2015)
VETERAN
CERTIFICATION OF DISABILITY
Purpose: Veterans use this form to certify to a qualifying disability and to apply for registration fee exemption and special
license plates.
Instructions: Send the completed form for validation to Veterans Services Officer, 210 Franklin Road, S.W.
Roanoke, VA. 24011. Submit validated form and your registration application to DMV at the address above.
MEDICAL PROFESSIONAL CERTIFICATION STATEMENT
I certify and affirm that the veteran applicant identified above has a PERMANENT DISABILITY which limits or impairs his/her ability to walk due to the reason indicated above. I also
certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all
supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or
representation on this form is a criminal violation.
MEDICAL PROFFESSIONAL NAME (print) MEDICAL LICENSE NUMBER ISSUING STATE EXPIRATION DATE (mm/dd/yyy)
MEDICAL PROFESSIONAL SIGNATURE
DATE (mm/dd/yyyy) OFFICE TELEPHONE NUMBER OFFICE FAX NUMBER
VETERANS ADMINISTRATION USE ONLY
This veteran is certified disabled as follows under provision of Virginia law.
1.
Loss of sight, limb(s) or hand(s) Loss of use of limb(s) or hand(s) Permanently and totally disabled
2.
Other service-connected disability
VETERANS SERVICES OFFICER NAME (print)
VETERANS SERVICE OFFICER SIGNATURE
VETERAN APPLICANT INFORMATION
DISABLED VETERAN NAME DMV CUSTOMER NUMBER DEPARTMENT OF VETERANS AFFAIRS CLAIM NUMBER
CHECK THE APPROPRIATE BOX(ES) IF YOU ARE APPLYING FOR A LICENSE PLATE AND/OR PLACARD DISPLAYING
THE INTERNATIONAL SYMBOL OF ACCESS (DISABLED SYMBOL). NOTE: MEDICAL CERTIFICATION IS REQUIRED
DISABLED
PLATE
DISABLED PLACARD
(Permanent)
PHYSICIAN / PHYSICIAN'S ASSISTANT / NURSE PRACTIONER USE ONLY
This certification may be completed and signed by a Veteran Services physician or the applicant's choice of physician, physician's assistant, nurse practitioner
Cannot walk 200 feet without stopping to rest.
Has been diagnosed with Alzheimer's disease or another form of dementia.
Uses portable oxygen Is legally blind or deaf.
Cannot walk without the use of or assistance from any of the following: another
person, brace, cane, crutch, prosthetic device, wheelchair, or other assistive device.
Has been diagnosed with a mental or developmental amentia or delay that impairs
judgment including, but not limited to, an autism spectrum disorder.
Has a cardiac condition to the extent that functional limitations are classified in
severity as Class III or Class IV according to standards set by the American Heart
Association.
Is 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 60 millimeters of mercury on room air at rest.
Is severely limited in ability to walk due to an arthritic, neurological or orthopedic
condition.
Other debilitating condition that limits or impairs the ability to walk. SPECIFY CONDITION (required)
Other condition that creates a safety concern while walking because of impaired judgement or other physical, developmental or mental limitation. SPECIFY CONDITION (required)
CHIROPRACTOR / PODIATRIST USE ONLY
This certification may be completed and signed by the applicant's choice of chiropractor or podiatrist.
Cannot walk 200 feet without stopping to rest.
Is severely limited in ability to walk due to an arthritic, neurological or orthopedic
condition.
Cannot walk without the use of or assistance from any of the following: another person, brace, cane, crutch, prosthetic device, wheelchair, or other assistive device.
Other debilitating condition that limits or impairs the ability to walk. SPECIFY CONDITION (required)
