Fillable Hanicap Placard Application Mv 664.3.qxd (Village of Bellport)

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Hanicap Placard Application Mv 664.3.qxd (Village of Bellport)

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BROWSE VILLAGE OF BELLPORT (NY) FORMS
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GENERAL INSTRUCTIONS
Please read pages 1 and 2 of this packet before you complete the application on page 3. 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. For a description of these
disabilities
see Part 2 of the application on page 3 of this packet. A parking permit may be issued for either a permanent or temporary disability.
Permits are issued in the name of the person with the disability. You do not have to be a driver, or the registered owner of a vehicle, to get a
parking permit. Children of any age who have a severe disability are eligible for permits, as are persons who are legally blind.
1) To apply for the parking permit
:
(a) Fill out Part 1 of the application on page 3. If you have a
PERMANENT DISABILITY, have a Medical Doctor, Doctor of
Osteopathy, Physician Assistant, Nurse Practitioner, Doctor of Podiatric Medicine (for disabilities related to the foot) or Optometrist
(for blindness) fill out the “permanent disability” Medical Certification section in Part 2 of the application form and return the form to
you. If you have a TEMPORARY DISABILITY that requires the use of an assistive device, have a Medical Doctor or Doctor of
Osteopathy fill out the “temporary disability” Medical Certification section in Part 2 of the application form and r
eturn 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.
(b)
You must take your completed application to the appointed issuing agent for the city, town, or village where you live. DO NOT
SEND YOUR APPLICATION TO THE DEPARTMENT OF MOTOR VEHICLES (DMV)- DMV DOES NOT ISSUE PARKING PERMITS.
If
you have a driver license or a non-driver ID card that is issued by the NYS DMV, you must show the document to the issuing agent. The
issuing agent will write on your permit the last three digits of the nine-digit number that is printed on your license or non-driver ID card to
help law enforcement identify the actual permit holder and help limit abuse. YOU ARE NOT REQUIRED TO HAVE A DRIVER
LICENSE OR NON-DRIVER ID ISSUED BY THE NYS DMV IN ORDER TO GET A PERMIT.
NEW YORK CITY RESIDENTS - Send the application (form 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 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 International Symbol of Access. Please read important information about “PARKING IN NEW
YORK CITY” on page 2.
NASSAU COUNTY RESIDENTS - Call (516) 227-7399 (the Nassau County Office of the Physically Challenged) to find out
where to apply for a permit.
ALL OTHER NEW YORK STATE RESIDENTS - Call your local city, town or village hall to find out where the nearest agent who
issues permits is located. Most city, town or village clerks, and some police departments, issue permits. Most agents
accept form MV-664.1, but some agents have their own application form, and not all agents issue permits for temporary disabilities.
2) To apply 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. A person must be at
least age 16 to have a vehicle registered in his or her name.
(c) Fill out Part 1 of the application on page 3. A Medical Doctor, Doctor of Osteopathy, Physician Assistant, Nurse Practitioner,
Doctor of Podiatric Medicine (for disabilities related to the foot) or Optometrist (for blindness) must 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
get the plates at any Motor Vehicles office. Bring the completed application with you.
- To register your vehicle for the first time, you must provide all of the items required for an original registration and include proof
of your disability.
- If you have plates on your car, bring the plates with you to exchange for plates for persons with severe disabilities. You must fill out a
registration application (form MV-82) and pay $25.00 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 a vehicle registration, you will have to pay an additional $3.75
transaction fee.
- Personalized plates with the ISA are available from DMV’s Custom Plates office. For information, 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-664.1 (2/14)
PAGE 1 OF 4
www.dmv.ny.gov
USING LICENSE PLATES AND PARKING PERMITS
u The plates and permits may be used to park in reserved parking spaces only when the person with the disability rides in or
drives the vehicle
. People who are not disabled cannot use your parking permit or special plates to park in a reserved space;
persons who park 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 that is committed within two years. Municipalities can impose
higher fines. Any person who abuses or misuses any parking permit or license plates for the disabled may have the permit or
plates revoked.
u Parking permits should be hung from the rear-view mirror when the vehicle is parked, but should be removed from the mirror
when the vehicle is driven
.
u Generally, 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 or the
requirement to obtain permission to park in a designated area. The plates and permits are also valid in most other states,
territories and foreign countries. If you will travel outside of New York, check with the police or Motor Vehicles agency in the
location where you will be to be sure your permit or plate will be accepted.
u Parking spaces reserved for people with disabilities must be marked with conspicuous and permanently installed above-grade
signs that display 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.
u 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, contact the authority that maintains 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.
u PARKING IN NEW YORK CITY
New York City (NYC) does not
reserve spaces on its streets for persons with disabilities. Reserved parking spaces are only
available off-street, in parking lots for shopping centers, malls, office buildings, apartment buildings, and college campuses.
You can use the special plates and permits to park in designated spaces in those off-street lots.
The NYC Department of Transportation issues a City permit
(a rectangular dashboard permit) that allows persons with
severe disabilities to park at most curbsides on NYC streets
. The NYC parking permit is not valid outside of NYC.
To obtain an application for a NYC permit, call (718) 433-3100 or visit the NYC Department of Transportation website at
www.nyc.gov/dot.
u METERED PARKING WAIVERS
If you have a mobility-related disability and a certain severe disability that limits your ability to access or put payment into a
parking meter, you may be eligible for a metered parking waiver. The metered parking waiver allows the holder to park in a
metered parking space in any city, town or village of New York State without paying the fee. For more information, see forms
MV-664.1MP (Application for a Metered Parking Waiver for Persons with Severe Disabilities) and MV-664.2MP (Metered
Parking Waiver Information). These forms are available through your local issuing agent and are also available on the DMV
website at www.dmv.ny.gov.
MV-664.1 (2/14)
PAGE 2 OF 4
o Uses portable oxygen o Legally blind o Limited or no use of one or both legs o Unable to walk 200 ft. without stopping
o Neuromuscular dysfunction that severely limits mobility o Class III or IV cardiac condition. (American Heart Assoc. standards)
o Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition
o 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
o 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.
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Last Name First M.I. Telephone No.
( )
o Blue o Red Parking Permit No. __________________ Date Issued:_______________ Date Expires:_____________________
o First o Second 9-digit number from NYS Driver License/ID Card ______________________________
o Denied o Revoked Reason:________________________________________________________________ _________________
___________________________________________________________________________________
o 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
Read note on page 4 before you sign
Read note on page 4 before you sign
Address: No. and Street Apt. No.
Date of Birth
o Male o Female I want: o License Plates (Apply to DMV.) o A Parking Permit (Apply to your local issuing agent.)
Do you have license plates for persons with disabilities? o Yes - My license plate number is:__________________ o No
City State Zip Code
(Signature of Person with Disability or Signature of Parent or Guardian) — If signed by a parent or guardian,
please write your relationship to the person with the disability after your signature.
Please read pages 1 and 2 of this packet before you complete this application. If you apply for a parking permit, take the completed application
to the issuing agent (local municipality) in the city, town or village where you live; do not send your application to the Department of
Motor Vehicles because DMV does not issue parking permits.
Part 3 FILE INFORMATION (For Issuing Agent Use Only)
(Locality)
(Issuing Agent)
(Date)
NOTE: PERMANENT DISABILITIES may be certified by a Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA),
Nurse Practitioner (NP), a Doctor of Podiatric Medicine (DPM, for disabilities related to the foot) or Optometrist (OD, for blindness).
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:
o 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/OD Name
Professional License No.
MD/DO/DPM/NP/PA/OD Address
Telephone No.
( )
(Date)
(Date)
ç
ç
ç
(MD/DO/DPM/NP/PA/OD Signature)
PAGE 3 OF 4
MV-664.1 (2/14)
Please
TEAR at the PERF
and keep pages 1 & 2
for your information.
É
reset/clear
www.dmv.ny.gov
MV-664.1 (2/14)
PAGE 4 OF 4
NOTE TO CUSTOMERS AND MEDICAL PROFESSIONALS
According to the NYS Vehicle and Traffic Law and the Penal Law, it is a crime (a felony or a
misdemeanor) to make a false statement or to provide false information on an application for a
parking permit or license plates for a person with severe disabilities. This crime is punishable by
a fine, imprisonment, or both. If this crime involves an application for a parking permit, the
crime may also result in liability for payment of a civil penality of $250 - $1,000.
For Customers Who Want License Plates, or a Parking Permit, for Persons with a Disability:
When you sign Part 1 of this application, you certify:
l that the information you provide on this application is true;
l that you have read and understand the conditions for “Using License Plates and Parking Permits” stated
on page 2; and
l that you agree to comply with those conditions.
For Medical Professionals Who Provide Medical Information in Support of an Application for
License Plates, or a Parking Permit, for Persons with a Disability:
When you sign Part 2 of this application, you certify:
l that the medical information you provide is true and complete; and
l 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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Hanicap Placard Application Mv 664.3.qxd (Village of Bellport)

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Completed 15 July 2020

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