Fillable Form MV-664.1MP APPLICATION FOR METERED PARKING WAIVER FOR PERSONS WITH SEVERE DISABILITIES

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Form MV-664.1MP APPLICATION FOR METERED PARKING WAIVER FOR PERSONS WITH SEVERE DISABILITIES

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The Form MV-664.1MP APPLICATION FOR METERED PARKING WAIVER FOR PERSONS WITH SEVERE DISABILITIES form is 1 page long and contains:

  • 2 signatures
  • 3 check-boxes
  • 27 other fields

Country of origin: US
File type: PDF

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APPLICATION FOR A METERED PARKING WAIVER
FOR PERSONS WITH SEVERE DISABILITIES
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.
INFORMATION ABOUT PERSON WITH DISABILITY
— (Please print, and sign by the arrow.)
Last Name First M.I.
Date of Birth
Male
Female
Address: No. and Street Apt. No. City State Zip Code
T
elephone No.
( )
Driver License Number and Expiration Date:
Do you have license plates for persons with disabilities? No Yes, plate number is:
Do you have a parking permit for persons with disabilities? No Yes, permit number is:
(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.
(Date)
X
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.
MEDICAL CERTIFICATION—This section must be completed only by a physician, physician assistant (PA), or doctor of
osteopathy (DO).
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).
+ Part A
•
Uses portable oxygen
•
Legally blind
•
Limited or no use of one or both legs
•
Unable to walk 200 ft. without stopping
•
Neuromuscular dysfunction that severely limits mobility
•
Class III or IV cardiac condition. (American Heart Association standards)
•
Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition
•
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
•
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.
+ 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):
Fine motor control of both hands
Ability to reach or access a parking meter due to use of a wheelchair or other ambulatory device
Ability to reach a height of 42 inches from the ground due to lack of finger, hand, or upper extremity strength or
mobility.
Physician/PA/DO Name (Print/Type)
Professional License No.
Physician/PA/DO Address (Print/Type)
Telephone No.
( )
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.
(Date)
(Physician/PA/DO Signature)
File Information (For Issuing Agent Use Only)
MV-664MP No. Issued:
Date Issued: MV-664 No. Issued:
MV-664.1MP (2/17)
PAGE 1 OF 2
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INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR A METERED PARKING WAIVER
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.
New York City Residents - New York City does not issue the Metered Parking Waiver because the New York City parking permit
allows the permit holder to park in metered parking spaces within New York City and not pay the meter fee. For more information
about the City permit, call (718) 433-3100 or contact the New York City Department of Transportation at:
New York City Department of Transportation
Permits and Customer Service
30-30 Thomson Avenue, 2nd Floor
Long Island City, NY 11101-3045
STEP 1 - Metered Parking Waiver Requirements
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 (New York City residents are not eligible as
explained above); 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.
STEP 2 - Complete the section “Information About Person with Disability”.
• 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.
STEP 3 - Have your doctor fill out the Medical Certification section.
• 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/P
A/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.)
STEP 4 - Bring your completed application to the issuing agent in the area where you live to receive a waiver.
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.
MV-664.1MP (2/17)
dmv.ny.gov
PAGE 2 OF 2
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Form MV-664.1MP APPLICATION FOR METERED PARKING WAIVER FOR PERSONS WITH SEVERE DISABILITIES

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Completed 10 February 2020

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