Delaware

DMV (Delaware Division of Motor Vehicles)

FORM MV474
APPLICATION FOR SPECIAL LICENSE PLATE OR SPECIAL PARKING ID PLACARD FOR PERSONS WITH DISABILITIES

Original application must be submitted. Photocopies, faxes, and downloaded or scanned applications cannot be accepted. FOR OFFICE USE ONLY (Placard) FOR OFFICE USE ONLY (HP Plate)

Parking ID Placard No: Current

Renewal

Special Parking Plate No:

Issue Date:

Expiration Date:

Initial Application (No Fee)

Renewal (No Fee) Replacement Placard $1.00

Section A - APPLICANT: COMPLETE THIS SECTION BEFORE PHYSICIAN CERTIFICATION (Must be completed for all Special Parking ID / Placard requests)

Applicant's Name:

Street Address:

City, State, Zip:

Driver's License or ID Number:

Date of Birth:

Section B - COMPLETE THIS SECTION IF APPLYING FOR A SPECIAL PARKING LICENSE PLATE
INDIVIDUAL MUST BE OWNER OF VEHICLE OR HOUSEHOLD MEMBER TO QUALIFY FOR A SPECIAL LICENSE PLATE FOR PERSONS WITH DISABILITIES (COMPLETE BELOW)

Make & Year of Vehicle:

Current Tag Number:

VIN Number:

Expiration Date:

Gross Weight of Vehicle: (14,000 lb. limit)

NOTE: Can only be used on vehicles that have GVWR (Gross Vehicle Weight Rating) that does not exceed 14,000 lbs.

Section C - COMPLETE THIS SECTION IF APPLYING FOR A LONG TERM PLACARD

I am applying for a special parking ID placard. I understand that it must be displayed on the rearview mirror of the vehicle whenever such vehicle is parked in a disabled parking space. This placard must be removed when the vehicle is in motion. I also understand that the placard expires in three (3) years and must be renewed.

Check for HP Placard

NOTE: NOTE: Can only be used in vehicles that have GVWR (Gross Vehicle Weight Rating) that does not exceed 14,000 lbs.

Section D - (Long Term Renewals and Replacements only)
SELF-CERTIFICATION FOR SPECIAL LICENSE PLATE OR PARKING ID PLACARD FOR PERSONS WITH DISABILITIES

I certify, under penalty of the law, that my medical condition has not changed, and I still require a permanent special license plate and/or parking ID placard.

Signature of Applicant:

Date

**NOTE: A PHYSICIAN'S SIGNATURE IS NOT REQUIRED TO RENEW A PLATE OR PLACARD FOR A PERSON WITH A PERMANENT DISABILITY OR IF THE APPLICANT IS 85 AND OLDER**

Section E - THE FOLLOWING SECTION MUST BE COMPLETED BY YOUR PHYSICIAN FOR FIRST TIME
ISSUANCE OF PLACARD/LICENSE PLATE OR RENEWAL OF A TEMPORARY PLACARD

In accordance with 21 Del.C. §2134 Eligibility, by law, for a long-term plate or placard is restricted to permanent disabilities with no prognosis for improvement. (NO OTHER PERSON IS ELIGIBLE FOR A LICENSE PLATE OR PLACARD)

A physician must certify this application. Applicant must meet one of the following requirements with no prognosis for improvement:

1. Cannot walk 200 feet without stopping to rest. 2. Cannot walk safely without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair or other assistive device. 3. Is restricted by lung disease to such an extent that the applicant's or household member's forced (respiratory) expiratory volume, one second, when measured by spirometry, is less than one liter or the arterial oxygen tension is less than sixty mm/hg. at room air or rest. 4. Uses portable oxygen. 5. Has a cardiac condition to the extent that the applicant's or household member's functional limitations are classified in severity as Class III or Class IV according to the standards set by the American Heart Association. 6. Is severely limited in their ability to walk due to an arthritic, neurological or orthopedic condition.

Section F - TEMPORARY PLACARD ONLY

In accordance with 21 Del.C. §4183 I am applying for a temporary special parking ID placard. I understand it must be displayed on the rearview mirror of the vehicle whenever such vehicle is parked in a disabled parking space. This placard must be removed when the vehicle is in motion. I also understand that the placard has an expiration date and may be renewed. NOTE: A new application must be completed and signed by your physician prior to renewing your temporary placard.

In accordance with 21 Del.C. §2135 Eligibility, by law, for a temporary special parking ID placard is restricted to a physical disability that is not permanent, but that substantially limits or impairs the applicant's or household member's ability to walk for not less than five (5) weeks, and which is so severe that the person would endure a hardship or be subject to a risk of injury without a temporary special ID placard.

Check for Temporary Only

(NO OTHER PERSON IS ELIGIBLE FOR A SPECIAL PARKING ID PLACARD)

THE TEMPORARY SPECIAL PARKING ID PLACARD ISSUED TO THE APPLICANT IS LIMITED TO (MINIMUM 35 DAYS/MAXIMUM 90 DAYS).

Section G - ***PHYSICIAN MUST PROVIDE THEIR CERTIFICATION BELOW

I certify, under penalty of law, that the above information concerning the applicant is true and correct, and that the applicant or household member meets the requirements specified above for the long-term special license plate/parking ID placard or temporary special parking ID placard. Date: Signature of Physician:

Date

Signature of Physician

License #:

PRINT NAME, ADDRESS AND TELEPHONE NUMBER OF LICENSED PHYSICIAN and APPLICANT NAME:

Physician's Name

Street Address or P.O. Box

City, State and Zip

Applicant Name

Telephone Number (Physician's office)

Contact Name (Physician's office)

In accordance with 21 Del.C. §2135 (i)(1) I certify, under penalty of law, that the above information is true and correct. I also understand that false representation by me can lead to penalties as provided by law as follows: Any person who is not disabled, as defined above, and who intentionally and falsely represents that such person has the qualifications to obtain such a special license plate or parking ID placard in an attempt to obtain such plate or placard shall for the first offense be fined $100. For each subsequent like offense, the person shall be fined $200 or imprisoned not less than 10 or more than 30 days, or both.

NOTE: I understand the special license plate and/or parking ID placard must be returned when no longer needed.

Signature of Applicant:

Date

Approved (Name of DMV Associate)

Delaware

DMV (Delaware Division of Motor Vehicles)

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