New Renewal
(placard). Apply at the Tag Office in the county in Georgia where you reside.
*Vehicle Owner’s Street Address including city, state & zip
Disabled Person’s Full Legal Name
*Relationship to Vehicle Owner- Check only one box
Child Self Spouse Ward
* Disabled Person's Driver’s License # & Name of Issuing State(if applicable)
Disabled Person’s Street Address including City, State & ZIP
Active Military Duty
Retired GA Veteran
Institution’s Full Legal Name (Institution as defined by Georgia Law §31-7-1)- Attach a copy of institutional license
Institution Authorized Representative’s Signature & Position –‘PARKING PERMITS (Placards) ONLY’
Check applicable box(s) below: You may apply for both a Disabled Person’s Parking Permit and Disabled Person’s License Plate with this form.
Temporary Parking Permit (Placard) No Fee-Termination date of disability: ______________________________________
Permanent Parking Permit (Placard) No Fee- Must be replaced every four (4) years from issue date.
Special Permanent Parking Permit (Placard) No Fee-Because of a physical disability, drives a motor vehicle which has been equipped with hand controls for
the operation of the vehicle’s brakes and accelerator; or is physically disabled due to the loss of, or loss of use of, both upper extremities. Must be replaced
every four (4) years from issue date.
Disabled Person’s License Plate (Fee $20.00 plus any taxes that may be due).
Is disability permanent? Yes No-Temporary permits shall be issued for no more than 180 days
I hereby swear and affirm that the above individual as defined by Georgia Law §24-9-101 and §460-6-221(5):
Is so ambulatory disabled that he/she cannot walk 200 feet without stopping to rest.
Cannot walk without use of assistance from a brace, a cane, a crutch, another person, a prosthetic device, a wheelchair, or other assistive device.
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.
Uses portable oxygen.
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.
Is severely limited in his/her ability to walk due to an arthritic, neurological, orthopedic condition or complications due to pregnancy.
Is hearing impaired pursuant to Georgia Law §24-9-101.
accompanied by a limit to the field or vision in the better eye to such degree that is widest diameter subtends and angle of no greater than twenty-degrees(20).
Licensed Doctor’s Printed Name
Office Street Address including City, State & ZIP
Telephone # including area code
Note: Notarization Required For Licensed Doctor’s Signature
Sworn to and subscribed before me
This ________ day of ______________________, ______
(Day) (Month) (Year)
Notary Public’s Signature & Notary Seal or Stamp
Date My Notary Commission Expires
County and State Use Only
* Retention Schedule: This form will be retained at the County Tag Office for two (2) years from the date issued.
Disabled Person’s Parking Permit # ______________________________________
motor.etax.dor.ga.gov
Is 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
Section Five - Certification
Section Four - To be completed by a licensed doctor of medicine, osteopathic medicine, podiatrist, optometrist or a licensed chiropractor.
Section One - Except for signature(s), this form must be typed, electronically completed and printed or legibly hand printed.
Note: The vehicle owner information is only required when applying for a DP license plate. You do not have to own a vehicle to obtain a DP parking permit
_______________
#
Section Two - For Institutions Only: This vehicle is used primarily for the transportation of disabled persons.
MV-9D (rev. 1-2013) Disabled Person’s Parking Affidavit
* Vehicle Owner’s Full Legal Name
* Driver’s License # & Name of Issuing State
(person operating vehicle)
