A.) A PERSON WITH DISABILITY INFORMATION - LIST NAME AND ADDRESS OF PERSON WITH DISABILITY - NOTE: If listing an out-of-state address, you must also complete and attach Form MV-8.
NOTE: If you are the parent or adult charged by law with the natural parent’s rights, duties and responsibilities acting on behalf of a minor child (under 18) in place of the child’s natural parents (person in
loco-parentis), you must complete the information below. In addition, a parent, including an adoptive or foster parent who has custody care or control of the child or adult child or a spouse may sign on behalf of the child, adult child or spouse (applicant) provided the applicant meets eligibility requirements (1) through (8).
B. CERTIFICATION FROM A HEALTH CARE PROVIDER LICENSED OR CERTIFIED IN PA OR A ONTIGUOUS STATE (NEW YORK, NEW JERSEY, DELAWARE, MARYLAND, WEST VIRGINIA OR OHIO). THIS SECTION MUST BE COMPLETED IN FULL. HEALTH CARE PROVIDERS MAY ONLY CERTIFY DISABILITIES WITHIN THEIR SCOPE OF PRACTICE. WARNING: Altering or forging a document issued by the Department, such as a disabled person parking placard, or possessing, using or displaying such a document knowing it to have been altered, forged or counterfeited, is a misdemeanor of the first degree pursuant to the Vehicle Code, 75 Pa.C.S. Section 7122, punishable by a fine of not more than $10,000 or imprisonment of not more than five years, or both.
I hereby certify that the person with the disability listed above is under my care and has the following condition listed on the reverse side of this application under “Eligibility Requirements”: _______________
(NOTE: Only those conditions listed on the reverse side of this application qualify an applicant for a person with disability placard.)
NOTE: If reason code #1 is listed above, please indicate the individual's visual acuity by completing the chart to the right: If reason code #4 is listed above, please indicate the type of device used: ________________________________________________
Temporary placards are only issued for a period of time not to exceed six months. If the applicant requires additional time after the expiration of the placard issued, the applicant must be recertified by a health care provider.
C. CERTIFICATION BY POLICE OFFICER - Police officer may only certify that the applicant does not have full use of a leg or both legs, or is blind.
NOTE: If Section B above is completed, please skip this Section and go on to Section E.
This is to certify that the person with disability listed above has the condition listed and is entitled to the use and privileges of the person with disability parking placard.
is blind, OR does not have full use of a leg or both legs as evidenced by the use of a: qwheelchair qwalker qcrutches q cane/quad cane q other prescribed device-_____________
D. CERTIFICATION FROM U.S. DEPARTMENT OF VETERANS AFFAIRS REGIONAL OFFICE ADMINISTRATOR (PHILADELPHIA OR PITTSBURGH) OR SERVICE UNIT IN WHICH THE VETERAN SERVED OR A LEGIBLE PHOTOCOPY OF THE APPLICANT'S LETTER OF PROMULGATION, AWARDS LETTER, SINGLE NOTIFICATION, OR SUMMARY OF BENEFITS LETTER.
This is to certify that the veteran listed above with VA number ___________________________, has a 100% service-connected disability or has the following service connected disability reason code number _______, listed on the reverse side of this application under “Eligibility Requirements.” NOTE: If reason code #4 is listed, please indicate the type of device used: __________________________.
E. NOTARIZATION AND APPLICANT SIGNATURE - Person with disability, natural parent or other authorized person listed in Section A must sign below.
SUBSCRIBED AND SWORN TO BEFORE ME:
SIGN IN PRESENCE OF NOTARY
I state that I have read and signed this application after its completion, and I swear or affirm that the statements made herein are true and correct, and that any statement made on or pursuant to this application is subject to the penalties of 18 Pa.C.S. Section 4903 (a)(2) (relating to false swearing), which shall include punishment of a fine not exceeding $5,000, or to a term or imprisonment of not more than two years, or both.
THIS APPLICATION MAY BE DUPLICATED
