Fillable Handicapped Parking Permit mv-664.3.qxd

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GENERAL INSTRUCTIONS
You are eligible for a special parking permit or license plates if you are a New York State resident who has one or more severe disabilities
that impair your mobility. See Part 2 of the MV-664.1 (Application for a Parking Permit or License Plates, for Persons With Severe
Disabilities) for a description of qualifying disabilities.
1) If you are applying for the p
arking permit:
NOTE: DO NOT SEND YOUR APPLICATION TO THE DEPARTMENT OF MOTOR VEHICLES. DMV DOES NOT ISSUE P
ARKING PERMITS.
(a) A parking permit may be issued for either a permanent or temporary disability.
(b) You do not have to be a driver, or the registered owner of a vehicle, to get a parking permit. Children who have a qualifying disability are
eligible for permits at any age, as are persons who are legally blind. Permits are issued in the name of the person with the disability.
(c) Fill out Part 1 of the application (MV-664.1). If you have a PERMANENT DISABILITY, have a Medical Doctor, Doctor of
Osteopathy, Physician Assistant, Nurse Practitioner, or Doctor of Podiatric Medicine (if the disability involves podiatry) fill out the
“permanent disability” section in Part 2 of the application form and return the form to you
. If you have a TEMPORARY
DISABILITY, have a Medical Doctor or Doctor of Osteopathy fill out the “temporary disability” section in Part 2 of the application
form and return the form to you
. NOTE: If you have a permanent disability, the need for medical certification may be waived by the
issuing agent if you have an obvious, visually-identifiable disability (such as the loss of a leg) OR
if you already have license plates
for persons with severe disabilities. If you have plates for persons with severe disabilities, fill out Part 1 of the application and attach a
copy of your registration to your application. If you have custom plates for persons with severe disabilities, bring a photo of your plate
showing the wheelchair symbol.
(d) You must take your completed application to the appointed issuing agent for the city, town or village where you live. If
you have a driver license or a non-driver ID card issued by NYS DMV, section 1203-a(1) of the NYS Vehicle and Traffic Law
requires you show it to the issuing agent in order to obtain a permit. The issuing agent must write the last three digits of
the nine-digit number that appears on your license or non-driver ID card. Marking the permit with the last three digits aids law
enforcement in identifying the actual permit holder and may help limit abuse. NOTE: IF YOU DO NOT HAVE A DRIVER
LICENSE OR NON-DRIVER ID ISSUED BY NYS DMV, YOU ARE NOT REQUIRED TO OBTAIN ONE IN ORDER TO
GET A PERMIT.
MOST NEW YORK STATE RESIDENTS - Call your local city, town or village hall to find out where the nearest permit issuing
agent is located. Most city, town or village clerks, and some police departments, issue permits. Although most agents
accept the MV-664.1, some have their own application form, and not all agents issue permits for temporary disabilities.
NASSAU COUNTY RESIDENTS - Call (516) 227-7399 (the Nassau County Office of the Physically Challenged) to find out
where to apply for a permit.
NEW YORK CITY RESIDENTS - Send the application (MV-664.1) to the NYC Department of Transportation, 28-11 Queens Plaza
North, 8th Floor, Long Island City, NY 11101-4008, or call (718) 433-3100. If you already have plates for persons with severe
disabilities, complete Part 1 and attach a copy of your registration. If you have custom plates for persons with severe disabilities, attach
a photo of your plate showing the ISA. Please read important information about “P
ARKING IN NEW YORK CITY” on page 2.
2) If you are applying for license plates:
(a) Your disability must be permanent.
(b) The vehicle on which the special plates will be used must be registered to the person with the disability, whether or not
that person drives. You must be at least 16 years old to have a vehicle registered in your name.
(c) Fill out Part 1 of the application (MV-664.1). Have a Medical Doctor, Doctor of Osteopathy, Physician Assistant, Nurse Practitioner,
or Doctor of Podiatric Medicine (if the disability involves podiatry) fill out the “permanent disability” section in Part 2 of the
application form and return the form to you
. NOTE: The need for a medical certification may be waived by the Motor Vehicles office
if you are permanently disabled and have an obvious, visually-identifiable disability (such as the loss of a leg) OR
if you have a
permanent (blue) parking permit for the disabled. Permit holders should bring the permit with them and, also, fill out Part 1 of the
application and attach a copy of the permit application showing the medical certification or doctor’s statement.
(d) You can obtain the plates at any Motor Vehicles office. Bring the completed application with you.
- If you are registering your vehicle for the first time, you must provide all of the items required for an original registration,
including the proof of disability.
- If you already have plates on your car, bring them with you to exchange them for plates for persons with severe disabilities. You will
have to fill out a registration application (MV-82) and pay $15.00 for the new plates that show the International Symbol of Access (ISA).
If this transaction is done at any time other than when you renew the vehicle registration, a $3.00 transaction fee will be charged.
- Personalized plates with up to six characters and the ISA are available from DMV’s Custom Plates office. Call (518) 402-4838.
New York State Department of Motor Vehicles
HOW TO APPLY FOR A PARKING PERMIT OR LICENSE PLATES
FOR PERSONS WITH SEVERE DISABILITIES
MV-664.3 (11/08)
PAGE 1 OF 2
www.nysdmv.com
USING LICENSE PLATES AND PARKING PERMITS
N The plates and permits may be used to park in reserved parking spaces only when the person with the disability is
driving or riding in the vehicle. People who are not disabled cannot use your parking permit and/or plates to park in a
reserved space. Persons parking illegally in these spaces violate Section 1203-c(4) of the NYS Vehicle and Traffic Law and
can be fined $50 to $75 for a first offense, and $75 to $150 for a second offense within two years. Municipalities can impose
higher fines. Any person who abuses any privilege, benefit, precedence or consideration arising from possession of the license
plates or permit, may have them revoked.
N Parking permits should be hung from the rear
-view mirror when parked
, but should be removed from the mirror when driving.
N The plates and permits are valid everywhere in New York State where parking spaces are reserved for persons with disabilities.
However, use of the plates or permit does not exempt you from state or local parking regulations or fees. They are also valid
in most other states, territories and foreign countries. If you are traveling outside of New York, check with the police or Motor
Vehicles agency where you are traveling, to be sure your permit or plate will be accepted.
N Parking spaces reserved for people with disabilities must be marked with conspicuous and permanently installed above-
grade signs displaying the wheelchair symbol. These signs are positioned at a height of five to seven feet above the parking
space surface. Designation of reserved spaces may include the use of blue painted lines or markings. Do not park in the
striped access aisle next to spaces reserved for people with disabilities even if you have a permit or plates.
Access aisles provide room for people with wheelchairs and other specially equipped vehicles to transfer safely to and from
their vehicles.
N Localities designate parking spaces for persons with disabilities by local law or ordinance. If you have a question about
parking for the disabled on a particular street, find out if it is a county, city, town, village or state road, and contact the
authorities responsible for maintaining the road. If you have a question about reserved parking at any facility with off-street
parking, contact the facility manager or the local building inspector.
N PARKING IN NEW YORK CITY
New York City does not
set aside reserved spaces on its streets for persons with disabilities. Such parking is only available
off- street, in parking lots for shopping centers/malls, office/apartment buildings and college campuses. You can use the state
plates and permits to park in designated spaces in those off-street lots.
The NYC Department of Transportation also issues a City permit
(a rectangular dashboard permit) that allows persons with
severe disabilities to park at most curbsides on NYC streets
. City permits are issued to New York City residents and to people
who work or attend school in NYC, and who have a permanent disability that so severely affects their ability to walk that they
require the use of a private automobile. The New
York City parking permit is not valid outside of NYC. To obtain an
application for a NYC permit, call (718) 433-3100.
MV-664.3 (11/08)
PAGE 2 OF 2
Last Name First M.I. Telephone No.
( )
Blue Red Parking Permit No. __________________ Date Issued:_______________ Date Expires:_____________________
First Second 9-digit number from NYS Driver License/ID Card ______________________________
Denied Revoked Reason:________________________________________________________________ _________________
___________________________________________________________________________________
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 Assoc. 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.
EXPLAIN BELOW HOW THIS DISABILITY LIMITS FUNCTIONAL MOBILITY.
PERMANENT DISABILITY: A “severely disabled” person is any person with one or more of the PERMANENT impairments,
disabilities or conditions listed below, which limit mobility.
Diagnosis:____________________________________________________ Please check the conditions that apply:
New York State Department of Motor Vehicles
APPLICATION FOR A PARKING PERMIT OR LICENSE PLATES,
FOR PERSONS WITH SEVERE DISABILITIES
Part 1 INFORMATION ABOUT PERSON WITH DISABILITY — (Please print and sign by the arrow.)
Part 2 MEDICAL CERTIFICATION
See Note on Page 2
See Note on Page 2
Address: No. and Street Apt. No.
Date of Birth
Male Female I am applying for License Plates (Apply to DMV.) Parking Permit (Apply to local issuing agent.)
Do you have license plates for persons with disabilities? Yes - My license plate number is:__________________ No
City State 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.
Parking Permit Applicants: Take your completed application to the issuing agent for the city, town or village where you live. If
you have a driver license or a non-driver ID card issued by NYS DMV, bring it with you when you apply for the permit. Section 1203-a(1)
of the NYS Vehicle and Traffic Law requires you to show your license or non-driver ID to the issuing agent in order to
obtain a permit. If you do not have a driver license or non-driver ID, this requirement does not apply.
MV-664.1 (10/08)
Part 3 FILE INFORMATION (For Issuing Agent Use Only)
(Locality)
PAGE 1 OF 2
(Issuing Agent)
(Date)
NOTE: PERMANENT DISABILITIES may be certified by a Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA),
Nurse Practitioner (NP), or in cases involving podiatry, a Doctor of Podiatric Medicine (DPM). TEMPORARY DISABILITIES, however,
may be certified only by a Medical Doctor or Doctor of Osteopathy.
Check the box(es) that describe the disability, and fill in the diagnosis:
TEMPORARY DISABILITY: A person with a temporary disability is any person who is temporarily unable to ambulate without the aid of an
assisting device
. Examples of an assisting device include, but are not limited to, a brace, cane, crutch, prosthetic device, another person,
wheelchair or walker.
IMPORTANT: Temporary permits are issued for six months or less regardless of expected recovery date.
Diagnosis:_____________________________________________________
What assistive device is needed?_________________________________________________________________________
Expected Recovery Date:______________________
MD/DO/DPM/NP/PA Name
Professional License No.
MD/DO/DPM/NP/PA Address
Telephone No.
( )
(Date)
(Date)
(MD/DO/DPM/NP/PA Signature)
reset/clear
www.nysdmv.com
MV-664.1 (10/08)
PAGE 2 OF 2
NOTE TO CUSTOMERS AND MEDICAL PROFESSIONALS
Making a false statement or providing false information on an application for a parking permit or
license plates for persons with severe disabilities is a crime (a felony or a misdemeanor) under
the Vehicle and Traffic Law and the Penal Law, and is punishable by a fine, imprisonment or
both, and --regarding applications for parking permits--may also result in liability for payment of
a civil penalty of $250-$1,000.
Customers Requesting License Plates, or a Parking Permit, for Persons with a Disability
By signing Part 1 of this application, you are certifying:
that the information you provide on this application is true;
that you have read and understand the “Conditions for Using License Plates and Parking Permits” stated
on form MV-664.3; and
that you agree to comply with those conditions.
Medical Professionals Providing Medical Information in Support of an
Application for License
Plates, or a Parking Permit, for Persons with a Disability
By signing Part 2 of this application, you are certifying:
that the medical information you are providing is true and complete; and
that, in your opinion, the person named in Part 1 of the application is medically qualified to receive
license plates, or a parking permit, for persons with a disability, according to the medical criteria
specified in Part 2.
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