Application for Disabled Parking Placard/Plate
Mail to: Medical Affairs, PO Box 55889, Boston, MA 0 2205-5889 ● 857-368-8020 ● mass.gov/rmv
For Walk-in Service Only: Haymarket Center, 136 Blackstone Street, Boston, MA
p.1 MAB100_0218
This side of application must be completed in the disabled person’s name.
Please note the information required in this application may affect your driver’s license.
• Incomplete application will not be processed and will be returned.
• Both disabled person and healthcare provider must sign and date this application. The disabled person’s information must be provided in
sections A, B, and C. The healthcare provider must complete sections D and E.
• This application must be submitted to Medical Affairs within thirty (30) days of the healthcare provider’s certification.
• RMV Service Center locations do not process disability parking applications; dropping off at a service center location may add processing time.
• Additional documentation may be required.
A. Disabled Applicant Information
Date of Birth (MM/DD/YYYY)
Current Massachusetts Learner’s Permit, Driver’s License # (if applicable)
or MA ID
What is your Social Security Number?
Residential Address (Where you actually reside)
City State Zip Code
Mailing Address
(same as above)
Street
Apt. #
City
State
Zip Code
Cel
l
Home
Work
Emergency Contact Information: (optional)
Cell
Home
Work
Type:
Placard .............................No fee required for a placard. Disabled person is not required to have a vehicle registered in his/her name.
Plate .................................Only issued to individual who is primary owner with vehicle registered in his/her name. Registration fees apply.
Motorcycle Plate ..............Only issued to individual who is primary owner with vehicle registered in his/her name. Registration fees apply.
DV Plate Only issued to individual who: a) is primary owner with vehicle registered in his/her name; b) provide the DV
(Disabled Veteran) Plate Letter from the Veteran’s Administration listing service-connected disabilities and total
combined rating; c) has qualifying conditions which meet Medical Affairs guidelines and total at least 60% of the
service-connected disability.
C. Certification and Signature of Applicant
Rules:
• It is illegal to allow someone to use your
placard if you are not in the vehicle.
• It is illegal for an individual to have more than
one placard (temporary or permanent).
• It is illegal to provide false information (persons
can be prosecuted under Massachusetts Law).
• It is illegal to possess or display a counterfeit
placard (altered or photocopied).
• It is illegal to forge a healthcare provider’s
signature.
Acknowledgment:
• I have read the rules.
• I understand misuse of disabled parking may result in high motor vehicle citation fines ($500,
first offense), license suspension terms, and the revocation of my disabled parking privileges.
• I certify under the penalty of perjury that all the information provided in this application,
including the representation of my medical status/condition, is true and correct to the best of
my knowledge.
• AUTHORIZATION TO RELEASE MEDICAL RECORDS – I hereby authorize the healthcare
provider completing this form to discuss and release any or all medical records pertaining to its
content with or to representatives of the RMV.
• For applicants for Disabled Veteran plates, I hereby authorize the Veteran’s Administration to
release medical information concerning my service connected disability rating(s).
I have reviewed this completed Application Form and swear (affirm), under the penalties of perjury, that the information I have provided is true and complete.
I am aware that false statements are punishable by fine, imprisonment, or both under M.G.L. Chapter 90, Section 24B.
Signature of Disabled Person: ____________________________________________________ Date: _________________________
