Fillable RMV - MAB109 Application For Temporary Placard For Holders Of Disability Plates

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RMV - MAB109 Application For Temporary Placard For Holders Of Disability Plates

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Application for Temporary Placard for
Holders Of Disability PlatesRegistry of Motor Vehicles ● Medical Affairs Division
P.O. Box 55889 ●
Boston, MA 02205-5889
Phone: 857-368-8020 Fax: 857-368-0018
1 MAB109_0218
A. Applicant Information
Last Name
First Name
Middle Name
Suffix
License/ID #
Disability Plate #
Telephone #
B. Nature of Placard Need
According to the General Laws of Massachusetts, as a holder of a Disability plate, you may receive a temporary placard
“for good cause”. Examples of good cause include (1) you plan long distance travel in a vehicle other than your own (i.e.,
you’ll be out of state for a month and will be
overnight.
Please state the nature of your need for a placard:
Please state how long you will need the placard:
From (MM/DD/YYYY)
To (MM/DD/YYYY)
I understand that this Temporary Placard must be returned to the Medical Affairs Division upon expiration.
I certify under the penalty of perjury that the information I have provided is true and correct.
Signature: ________________________________________________________ Date: ____________________
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RMV - MAB109 Application For Temporary Placard For Holders Of Disability Plates

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Completed 12 May 2020

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