KANSAS
Department of Revenue
Division of Vehicle Services
https://www.ksrevenue.gov/pdf/tr159.pdf
Name of Disabled Individual, Business or Agency:
__________________________________________________________________________________________
Physical Address: __________________________________City___________________ KS ZIP ______________
Mailing Address: ___________________________________City_______________ State _____ Zip __________
Individual’s ONLY Date of Birth: _______________ Sex: Male Female
Signature ___________________________________Phone: _________________________ Date: __________
PLEASE CHECK APPROPRIATE APPLICATION(S):
1. DISABLED IDENTIFICATION PLACARD APPLICATION
Check only if applying for (lost, stolen) replacement placard. * No Licensed Professional's Statement needed for replacement placard.
*If Replacement Placard, Current Disabled ID Card Number: _____________________________________
O
nly applicants certified as PERMANENT disabled may apply for a disabled license plate.
2. DISABLED LICENSE PLATE APPLICATION (50¢ reflective plate fee)
Number________________ Plate Type________________
HEALING ARTS LICENSED PROFESSIONAL'S STATEMENT
Attending licensed professional must certify and sign the following:
3. WHEELCHAIR EMBLEM DECAL FOR LICENSE PLATE
I, the undersigned licensed professional, certify that (Disabled Individual's Name) __________________________________________
is considered to be disabled, as per Kansas Statute 8-1,124, due to at least one (1) or more of the following: (Must check at least one.)
1. H
as a severe visual impairment;
3. Cannot walk without the use of or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other
assistive device;
4. Is restricted by lung disease to such an extent that the person's 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 on room air at rest;
5.
Uses portable oxygen;
6.
Has a cardiac condition to the extent that the person's functional limitations are classified in severity as Class III or Class IV
according to standards set by the American Heart Association;
7.
Severely limited in their ability to walk at least 100 feet due to an arthritic, neurological, or orthopedic condition.
I certify that I am aware of the penalties provided by KSA 8-1,130(a)(b) listed on the back of this application.
________________________________________ ________________________________________________ _______________
Licensed Professional's Signature* (Rubber stamp not acceptable) Medical Title D
ate
* The follow
ing are the only professionals that can sign this form: Dr. of Medicine (MD), Dr. of Osteopathy (DO), Dr. of Chiropractic (DC), Dr. of Podiatric (DPM),
Licensed Optometrist (OD), licensed physician assistant (PA), advanced registered nurse practitioner (ARNP) registered under KSA 65-1131 or Christian Science
practitioner listed in The Christian Science Journal. (KSA Chapter 65, Article 28 and 8-1,125)
MUST check one (1) of the below and provide requested information:
2.
C
annot walk one hundred (100) feet without stopping to rest (Violation KSA 8-1,130);
PERMANENT ** From (Date) _________________To (Date) ____________________.
** Six (6) Months is the MAXIMUM Duration for a Temporary Placard.
Printed / Typed Name of Licensed Professional ______________________________________________Phone No.________________
May be signed by a Healing Arts Professional licensed in any state.
Address _______________________________________City _______________________ State_____ ZIP________________
TR-159
www (Rev. 2/2018)
SEE REVERSE SIDE FOR INSTRUCTIONS
_
TEMPORARY
Application for disabled placards, plates, decals and ID card must be made at
YOUR Local County Treasurer’s Motor Vehicle Office
CERTIFICATION OF DISABILITY FOR
DISABLED PARKING PLACARD/PLATE/DECAL
BUSINESS OR AGENCY REPRESENTATIVE MUST CERTIFY AND SIGN THE FOLLOWING:
I, the undersigned, certify that the above named agency or business is responsible for the transportation of person(s) to be
considered disabled as per K.S.A. 8-1,124, as out lined below, thus qualifying for accessible parking privileges.
_
Authorized Representative or Owner Signature (Rubber Stamp NOT Acceptable)
_________________________________________________________________________________________________________
Title
Date
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