Fillable and/or License Plate Disabilities Parking Placard Application for (Texas Department of Motor Vehicles)

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and/or License Plate Disabilities Parking Placard Application for (Texas Department of Motor Vehicles)

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License No
Parking Placard 1
Parking Placard
County No
Date Issued
First Name
Middle Name
Last Name
Suffix
Institution Name (if applicable)
Address
City
State
ZIP
Phone Number
the person with the disability listed above. DL or ID # and state of issuance
making application on behalf of a person with a disability and my vehicle is used to regularly transport the person with the disability.
DL or ID # and state of issuance
the administrator or man
ager of an institution licensed to transport persons with disabilities defined under Transportation Code,
Section 681.0032. DL or ID #
.
Chapter 242, 246, or 247 of the Health and Safety Code must list a facility ID # issued by the agency:
Disabled Person License Plate(s) with no Parking Placard One (1) Parking Placard with no Disabled Person License Plate(s)
Disabled Person License Plate(s) and one (1) Parking Placard Two (2) Parking Placards with no Disabled Person License Plate(s)
Vehicle Identification Number
Current TX Plate
Year
Make
Passenger Car (up to 18,000 lbs.) Truck (up to 18,000 lbs.) Motorcycle/Moped
Date:
Application for Persons with
Disabilities Parking Placard
and/or License Plate
County Use Only
Instructions
Persons with Disabilities Parking Placard: Submit the completed application and payment (if required) in the form of a personal check,
money order, or cashier’s check with proof of eligibility to your local county tax assessor-collector’s office or the county tax assessor-
collector’s office where you are seeking medical treatment.
Persons with Disabilities License Plate: Submit the completed application and payment (if required) in the form of a personal check,
money order, or cashier’s check with proof of eligibility to your local county tax assessor-collector’s office.
Contact the appropriate local county tax assessor-collector’s office for processing application by mail. Do not mail cash. Include a copy of
the photo identification (ID) if applying by mail.
IMPORTANT: The signature of a licensed medical professional must be notarized on page 2 if an original prescription is not submitted.
Otherwise an original prescription must include the disabled person's name, the signature of the licensed medical professional (as defined
on page 2), and a statement if the disability is permanent or temporary.
• A parking placard may be issued to persons with a permanent or temporary disability. There is no fee for a placard issued to
a person
with a permanent disability, and a $5 fee (per placard) if issued to a person with a temporary disability.
• Disabled Person license plates displaying the International Symbol of Access (ISA) may be issued to persons with a permanent
disability (limit one set of plates).
• Limit one (1) placard for persons with Disabled Person license plates. Limit two (2) placards for persons with no Disabled Person
license plates.
• Attach a separate application if an additional set of Disabled Person plates is needed for certain specially equipped vehicle(s) with gross
weight of 18,000 lbs. or less.
• Active duty U.S. military may list an out of state Driver License (DL) or military ID number.
• Non-Texas residents seeking medical treatment in Texas may provide an out of state or out of country DL or ID number.
Applicant Information
Identification Statement – State law makes falsifying information a third degree felony.
Please include your Driver License number (DL #) or Identification Card number (ID #) on this application. The DL or ID # provided on this
application will be partially shown on the placard issued. My signature below indicates that I am (check one):
Institutions, facilities, and r
esidential retirement communities licensed under
Application for Parking Placard(s) and/or Disabled Person License Plate(s) – Check one below.
Vehicle Information for License Plate(s) – Complete only if you are applying for Disabled Person plate(s).
Vehicle Type
Certification – State law makes falsifying information a third degree felony.
I meet the eligibility requirements as listed on this application and am providing proof to that effect, or I am making application on behalf
of a person with a disability as indicated in the Identification Statement above.
Signature:
Form VTR-214 Rev. 8/2019 Form available online at www.TxDMV.gov Page 1 of 2
Application for Persons with Disabilities Parking Placard and/or License Plate
Definitions
Transportation Code, Section 681.001(2) defines a disability as a condition in which a person has:
(a) mobility problems that substantially impair the person's ability to ambulate;
(b) visual acuity of 20/200 or less in the better eye with correcting lenses; or
(c) visual acuity of more than 20/200 but with a limited field of vision in which the widest diameter of the visual field subtends an
angle of 20 degrees or less.
Transportation Code, Section 681.001(5) defines a mobility problem as one that substantially impairs a person's ability to ambulate, and
the person:
(a) cannot walk 200 feet without stopping to rest;
(b) cannot walk without the use of or assistance from an assistance device, including a brace, cane, crutch, another person or a
prosthetic device;
(c) cannot ambulate without a wheelchair or similar device;
(d) is restricted by lung disease to the extent that the person's forced respiratory expiratory volume for one second, measured by
spirometry, is less than one liter, or the arterial oxygen tension is less than 60 millimeters of mercury on room air at rest;
(e) uses portable oxygen;
(f) 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;
(g) is severely limited in the ability to walk because of an arthritic, neurological, or orthopedic condition;
(h) has a disorder of the foot that, in the opinion of a physician licensed to practice medicine in this state or in a state adjacent to this
state, limits or impairs the person's ability to walk; or
(i) has another debilitating condition that, in the opinion of a physician licensed to practice medicine in this state or a state adjacent
to this state, or authorized by applicable law to practice medicine in a hospital or other health facility of the Veterans
Administration, limits or impairs the person's ability to walk.
Disability Statement – This section to be completed by a Licensed Medical Professional.*
* A Licensed Medical Professional is defined as a physician, podiatrist, optometrist, or qualifying physician's assistant or advanced practice
nurse as defined in Chapter 301, Occupations Code. At least one of the following conditions must be met:
• Licensed in Texas, Arkansas, Louisiana, New Mexico, or Oklahoma; or
• Must practice medicine in a U.S. military installation based in Texas; or
• Must practice medicine in a hospital or health facility of the U.S. Department of Veterans Affairs.
I certify that
has a
permanent, or
temporary disability as defined above
.
Printed Name of Person with a Disability or Mobility Problem
Printed Name of Licensed Medical Prof
essional Professional License Number Date
Signature of Licensed Medical Professional
Mailing Address City Sta
te ZIP
Notary – This section must be completed by a notary if an original prescription is not submitted.
On this date, the above named licensed medical professional
Date Name
Sta
te of
, County of
Notary Public
appeared before me so that I could witness his or
her signature.
My comm
ission expires
Date
Form VTR-214 Rev. 8/2019 Form available online at www.TxDMV.gov Page 2 of 2
S T A M P
H E R E
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andor License Plate Disabilities Parking Placard Application for (Texas Department of Motor Vehicles)

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Completed 9 January 2021

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