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 Treasurers 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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INSTRUCTIONS
Disabled individual shall be a Kansas resident.
Application shall be signed by the disabled individual, representative or owner of the vehicle which
transports them.
The personal disabled identification card shall be carried by the person to whom it is assigned when using
disabled parking privileges.
Disabled license plate will require a 50¢ reflective plate fee. Application for a disabled license plate must
be made at your local county treasurer's motor vehicle office.
A permanently disabled individual may select one of the following disabled parking choices:
o One (1) disabled license plate and/or one (1) placard, or
o Two (2) placards, but NO disabled license plate, or
o One (1) placard and 1 wheelchair emblem decal assigned to a specific distinctive plate
A temporarily disabled individual may be issued 1 or 2 temporary disabled placards.
The permanent or temporary disabled placard shall be suspended from rear view mirror when using
disabled parking privileges and may be transferred from one vehicle to another. The placard is to be
removed from the rear view mirror when the vehicle is being operated. (K.S.A. 8-1,125)
Upon death of the disabled individual, both the disabled license plate, wheelchair emblem decal, and/or
placard(s) and the personal disabled identification card(s) shall be returned to the local county treasurer's
office in exchanged for a regular county license plate if applicable.
The healing arts licensed professional's name must be printed/typed in the space provided. The licensed
professional must sign the application. It SHALL NOT be rubber stamped or just initialed. A healing arts
licensed professional is a: Dr. of Medicine (MD), Dr. of Osteopathy (DO), Dr. of Chiropractic (DC), or Dr. of
Podiatric (DPM). A healing arts licensed professional from any state can sign this form. A licensed
optometrist (OD), licensed physician assistant, advanced registered nurse practitioner registered under
K.S.A. 65-1131 or Christian Science practitioner listed in The Christian Science Journal can also certify the
form. A RN or LPN is not authorized to certify/sign this form.
The disabled identification card shall be available upon demand if the disabled individual is using any
disabled parking privilege. If the disabled individual is not in the vehicle or the disabled individual does not
have his or her ID card available upon demand, the vehicle is NOT entitled to use the disabled parking
privilege.
The disabled customer’s Disabled Identification Card for the TEMPORARY placard shall be carried by the
person it is issued to when using accessible parking. (K.S.A. 8-1,125)
PENALTY
Any person who willfully and falsely represents him/herself as having the qualifications to obtain a special license
plate, wheelchair emblem decal, a permanent placard and an individual identification card or temporary placard
pursuant to this act shall be guilty of a class C misdemeanor. Any person who falsely utilizes any parking privilege,
shall be guilty of an unclassified misdemeanor punishable by fines not exceeding $500. (K.S.A. 21-6611, K.S.A. 8-
1,130(a)(b) Violators may also be subject to additional penalties where imposed by local ordinance.
In addition to being eligible to park at marked accessible parking places, disabled persons having a valid
disabled plate, wheelchair emblem decal, or placard displayed on or in the vehicle may also park at parking
meters for a period of time not to exceed 24 hours and will be exempt from any parking fees of the state or
any city, county or other political subdivision. (K.S.A. 8-1,126)