Fillable Georgia Department of Revenue - Motor Vehicle Division (Cherokee County, Georgia)

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Georgia Department of Revenue - Motor Vehicle Division (Cherokee County, Georgia)

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Have a question? Visit our website at https://dor.georgia.gov/motor-vehicles or scan the QR code above for more information.
MV-9D (Revised 1-2019)
Web and MV Manual
Georgia Department of Revenue - Motor Vehicle Division
Person with Disability Parking Placard/License Plate Application
Purpose of this form: This form is to be used to request a Person with Disability Parking Placard or a Disabled Person’s License Plate. This form should not be
used to record a change of ownership, change of address, or change of license plate classification.
How to submit this form: After reviewing the MV-9D form instructions, this fully completed form must be submitted to your local County tag office. Please refer to
our website at https://dor.georgia.gov
to locate the address(es) for your specific county.
A
REQUEST TYPE
Check applicable box(es) below:
[ ] Disabled Person’s Parking Permit (Placard):
[ ] New Issuance: [ ] Temporary Plac
ard [ ] Permanent Placard [ ] Special Permanent Placard
[ ] Renewal (Permanent Placards Only) Record placard number
[ ] Replacement: [ ] Lost [ ] Stolen Record previous placard number
Placard No.: Record placard number if
renewing or replacing placard.
[ ] Disabled Person’s License Plate Fee: $20.00 Plate Fee plus any taxes that maybe due. Please Note: Section D must be completed and notarized.
B
APPLICANT INFORMATION
First Name
Middle Initial
Last Name
Suffix
Telephone No.:
Address:
Street No.
Street Name
Apt./Suite No.
City
State
ZIP Code
Driver’s License No.:
State of Issuance: County:
C
PARENT/GUARDIAN INFORMATION
Note: If you are the parent or adult charged by law with the natural parent’s rights, duties and responsibilities acting on behalf of a minor child
(under 18) in place of the child’s natural parents (person in loco-parentis), you must complete the information below.
Parent/Guardian’s
Full Legal Name:
First Name
Middle Initial
Last Name
Suffix
Relationship
to Applicant:
Physical
Address:
Street No.
Street Name
Apt./Suite No.
City
State
ZIP Code
Driver’s License No.:
State of Issuance: County:
D
CERTIFICATION FROM A LICENSED OR CERTIFIED HEALTH CARE PROVIDER
I hereby certify that the person with the disability listed above is under my care and has the following condition listed on the reverse side of this application under
“Eligibility Requirements.” Enter Reason Code No.: (Note: Only those conditions listed on the reverse side of this application qualify
an applicant for a Person with Disability Parking Placard.) **PLEASE SEE INSTRUCTIONS BEFORE COMPLETING**
Health Care Provider’
s Name:
Medical License No.:
Physical Address:
Street No., Street Name, Suite No.
City, State, ZIP Code
Telephone No.:
Signature:
Sworn to and subscribed before me
this
____ day of _______________, ______
Day Month Year
Notary Seal or Stamp
____________________________________
Notary Signature
____________________________
Commission Expiration Date
E
INSTITUTION/BUSINESS INFORMATION (This vehicle is used primarily for transportation of disabled persons.)
Institution/Business
Full Legal Name:
FEIN:
Vehicle Identification No.
:
Year
:
Make: Model: Tag No.:
Authorized Representative’s
Printed Name:
Position/ Job Title:
Authorized Representative’s
Signature:
Date:
/
/
F
APPLICANT SIGNATURE
I state that I have read and signed this application after its completion, and I swear or affirm that the statements made herein are true and correct, and I
acknowledge that any person knowingly or willfully making a false statement on or pursuant to this application is guilty of a misdemeanor under Georgia Code
§40-2-74(a.1).
Signatur
e:
Date:
/
/
PRINT
CLEAR
Have a question? Visit our website at https://dor.georgia.gov/motor-vehicles or scan the QR code above for more information.
INSTRUCTIONS
How to complete the MV-9D Form
COMPLETING THIS FORM
Temporary Placard: Complete Sections A, B, C, D and F. Note: Only licensed health care providers may certify disabilities for temporary placards. Temporary
placards may not be extended for an additional period of time. When additional time is needed, a new application must be completed and certified by a health
care provider. In addition, please list your previous placard number. Temporary placards are only issued for a period of time not to exceed six months.
Permanent Placard: Complete Sections A, B, C, D and F. Note: Individuals should list their Georgia Driver’s License number or Photo ID number in the space
provided. Businesses
should list their Business ID number (Bus. ID) where indicated (i.e., E.I.N.) and provide a copy of business license.
Special Permanent Placard: Follow the instructions for a Permanent Placard. A Special Permanent Placard (gold placard) is issued only to an individual with a
disability who (1) drives a motor vehicle equipped with hand controls for the operation of brakes and accelerator or (2) is disabled due to loss, or loss of use, of
both upper extremities.
Renewal Request: Complete Sections A, B and F. Note: Notarization is not required.
Replacement Request: Indicate if applying for a replacement placard. Please check reason for replacement (Lost or Stolen). List your previous placard
number
and complete Sections A, B and F.
Institution/Business Information: Complete Sections A, B, E and F. Follow these additional special instructions:
• Institutions, as defined by Georgia Code §31-7-1, must attach a copy of the institutional license. Note: To qualify for a permit, the institution must operate
the vehicle primarily to transport individuals with disabilities.
• Businesses, to qualify for a special plate, must meet the requirements of Georgia Code §40-2-74, including limits on the type of business organization.
Note: The business vehicle must be used only or primarily by the disabled employee for whom the plate was issued.
Please Note:
• A placard is to be used only when the vehicle in which it is displayed is parked and is being used for the transportation of the person with disability or the
severely
disabled veteran.
• Any vehicle lawfully displaying a placard will qualify for parking in areas designated for use by persons with disability only.
• The placard will not allow vehicles to park where parking is prohibited.
• The placard is required to be displayed when the vehicle is parked in areas designated for use by persons with disability only and must not be displayed
when
the vehicle is being operated on the highway.
• Each eligible individual will be issued only one placard.
ELIGIBILITY REQUIREMENTS – REASON CODES
1. Applicant is so ambulatory disabled that he/she cannot walk 200 feet
without
stopping to rest.
2. Applicant cannot walk without the use of assistance from a brace, a cane, a
crutch, another person, a prosthetic device, a wheelchair, or other assistive
device.
3. Applicant is restricted by lung disease to such an extent that his/her forced
respiratory volume for one second, when measured by spironmetry is less
than
one liter, or when at rest his/her arterial oxygen tension is less than 60
millimeters of mercury on room air.
4. Applicant uses portable oxygen.
5. Applicant has a cardiac condition to the extent that his/her functional
limitations are classified in severity as Class III or Class IV according to
standards set by the American Heart Association.
6. Applicant is severely limited in his/her ability to walk due to an arthritic,
neurological, orthopedic condition or complications due to pregnancy.
7. Applicant is hearing impaired person pursuant to Georgia Code §24-6-651.
8. Applicant is a blind individual whose central visual acuity does not exceed
20/200 in the better eye with correcting lenses or whose visual acuity, if
better than 20/200, is accompanied by a limit to the field of vision in the
better eye to such a degree that its widest diameter subtends an angle of
no greater than 20 degrees.
QUALIFYING VEHICLES
A passenger vehicle or truck with a registered gross weight of not more than 10,000 lbs. This restriction does not apply to institution or business applications.
CERTIFICATION FROM A LICENSED OR CERTIFIED HEALTH CARE PROVIDER
“For purposes of this Code section (40-2-74.1) the department shall accept, in
lieu of an affidavit, a signed and dated statement from the doctor which
includes
the same information as required in an affidavit written upon security
paper as
defined in paragraph (38.5) of Code Section 26-4-5."
Please Note: Certification in lieu of an affidavit (completion and notarization of
Section D) can only be submitted for placards and cannot be provided on
license plate applications.
Who may provide certification: Health care providers that are permitted to
provide a certification are limited to medical practitioners licensed to practice
under Article 2 of Chapter 34 of Title 43 (physicians); Chapter 35 of Title 43
(podiatrists); and Chapter 9 of Title 43 (chiropractors) of the Georgia Code.
SUBMITTING THIS FORM
After reviewing the MV-9D form instructions, this fully completed form must be submitted to your local County tag office. Please refer to our
website at https://dor.georgia.gov to locate the address(es) for your specific county.
Secured paper document (as defined by GA Code 26-4-5) from
healthcare provider must include:
• Specific disability as indicated on MV-9D instructions form.
• Indication of permanent or temporary disability
• Stamp or signature of healthcare provider
• Date
Jane Doe
123 Main St.
40
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Georgia Department of Revenue - Motor Vehicle Division (Cherokee County, Georgia)

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Completed 23 June 2021

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