New York State Department of Motor Vehicles HOW TO APPLY FOR A PARKING PERMIT OR LICENSE PLATES FOR PERSONS WITH SEVERE DISABILITIES www.dmv.ny.gov GENERAL INSTRUCTIONS Please read pages 1 and 2 of this packet before completing the application on page 3. You are eligible for a special parking permit or license plates if you are a New York State resident who has one or more severe disabilities that impair your mobility. For a description of qualifying disabilities see Part 2 of the application on page 3 of this packet. 1) If you are applying for the parking permit: NOTE: DO NOT SEND YOUR APPLICATION TO THE DEPARTMENT OF MOTOR VEHICLES. DMV DOES NOT ISSUE PARKING PERMITS. (a) A parking permit may be issued for either a permanent or temporary disability. (b) Permits are issued in the name of the person with the disability. You do not have to be a driver, or the registered owner of a vehicle, to get a parking permit. Children who have a qualifying disability are eligible for permits at any age, as are persons who are legally blind. (c) Fill out Part 1 of the application on page 3. If you have a PERMANENT DISABILITY, have a Medical Doctor, Doctor of Osteopathy, Physician Assistant, Nurse Practitioner, Doctor of Podiatric Medicine (for disabilities related to the foot) or Optometrist (for blindness) fill out the “permanent disability” Medical Certification section in Part 2 of the application form and return the form to you. If you have a TEMPORARY DISABILITY that requires the use of an assistive device, have a Medical Doctor or Doctor of Osteopathy fill out the “temporary disability” Medical Certification section in Part 2 of the application form and return the form to you. NOTE: If you have a permanent disability, the need for medical certification may be waived by the issuing agent if you have an obvious, visually-identifiable disability (such as the loss of a leg) OR if you already have license plates for persons with severe disabilities. (d) You must take your completed application to the appointed issuing agent for the city, town or village where you live. If you have a driver license or a non-driver ID card issued by NYS DMV, you must show it to the issuing agent in order to obtain a permit. The issuing agent will write the last three digits of the nine-digit number that appears on your license or non-driver ID card on your permit. Marking the permit with the last three digits aids law enforcement in identifying the actual permit holder and may help limit abuse. NOTE: IF YOU DO NOT HAVE A DRIVER LICENSE OR NON-DRIVER ID ISSUED BY NYS DMV, YOU ARE NOT REQUIRED TO OBTAIN ONE IN ORDER TO GET A PERMIT. NEW YORK CITY RESIDENTS - Send the application (MV-664.1) to the NYC Department of Transportation, 28-11 Queens Plaza North, 8th Floor, Long Island City, NY 11101-4008, or call (718) 433-3100. If you already have plates for persons with severe disabilities, complete Part 1 and attach a copy of your registration. If you have custom plates for persons with severe disabilities, attach a photo of your plate showing the ISA. Please read important information about “PARKING IN NEW YORK CITY” on page 2. NASSAU COUNTY RESIDENTS - Call (516) 227-7399 (the Nassau County Office of the Physically Challenged) to find out where to apply for a permit. ALL OTHER NEW YORK STATE RESIDENTS - Call your local city, town or village hall to find out where the nearest permit issuing agent is located. Most city, town or village clerks, and some police departments, issue permits. Although most agents accept the MV-664.1, some have their own application form, and not all agents issue permits for temporary disabilities. 2) If you are applying for license plates: (a) Your disability must be permanent. (b) The vehicle on which the special plates will be used must be registered to the person with the disability, whether or not that person drives. You must be at least 16 years old to have a vehicle registered in your name. (c) Fill out Part 1 of the application on page 3. Have a Medical Doctor, Doctor of Osteopathy, Physician Assistant, Nurse Practitioner, Doctor of Podiatric Medicine (for disabilities related to the foot) or Optometrist (for blindness) fill out the “permanent disability” section in Part 2 of the application form and return the form to you. NOTE: The need for a medical certification may be waived by the Motor Vehicles office if you are permanently disabled and have an obvious, visually-identifiable disability (such as the loss of a leg) OR if you have a permanent (blue) parking permit for the disabled. Permit holders should bring the permit with them and, also, fill out Part 1 of the application and attach a copy of the permit application showing the medical certification or doctor’s statement. (d) You can obtain the plates at any Motor Vehicles office. Bring the completed application with you. - If you are registering your vehicle for the first time, you must provide all of the items required for an original registration, including the proof of disability. - If you already have plates on your car, bring them with you to exchange them for plates for persons with severe disabilities. You will have to fill out a registration application (MV-82) and pay $25.00 for the new plates that show the International Symbol of Access (ISA). - If this transaction is done at any time other than when renewing a vehicle registration, an additional $3.75 transaction fee will be charged. - Personalized plates with up to six characters and the ISA are available from DMV’s Custom Plates office. Call (518) 402-4838. MV-664.1 (8/12) PAGE 1 OF 4 American LegalNet, Inc. www.FormsWorkFlow.com USING LICENSE PLATES AND PARKING PERMITS u The plates and permits may be used to park in reserved parking spaces only when the person with the disability is driving or riding in the vehicle. People who are not disabled cannot use your parking permit and/or plates to park in a reserved space. Persons parking illegally in these spaces violate Section 1203-c(4) of the NYS Vehicle and Traffic Law and can be fined $50 to $75 for a first offense, and $75 to $150 for a second offense within two years. Municipalities can impose higher fines. Any person who abuses or misuses any parking permit or license plates for the disabled may have them revoked. u Parking permits should be hung from the rear-view mirror when parked, but should be removed from the mirror when driving. u Generally, the plates and permits are valid everywhere in New York State where parking spaces are reserved for persons with disabilities. However, use of the plates or permit does not exempt you from state or local parking regulations or fees or the requirement to obtain permission to park in a designated area. They are also valid in most other states, territories and foreign countries. If you are traveling outside of New York, check with the police or Motor Vehicles agency where you are traveling, to be sure your permit or plate will be accepted. u Parking spaces reserved for people with disabilities must be marked with conspicuous and permanently installed abovegrade signs displaying the wheelchair symbol. These signs are positioned at a height of five to seven feet above the parking space surface. Designation of reserved spaces may include the use of blue painted lines or markings. Do not park in the striped access aisle next to spaces reserved for people with disabilities even if you have a permit or plates. Access aisles provide room for people with wheelchairs and other specially equipped vehicles to transfer safely to and from their vehicles. u Localities designate parking spaces for persons with disabilities by local law or ordinance. If you have a question about parking for the disabled on a particular street, find out if it is a county, city, town, village or state road, and contact the authorities responsible for maintaining the road. If you have a question about reserved parking at any facility with off-street parking, contact the facility manager or the local building inspector. u PARKING IN NEW YORK CITY New York City does not set aside reserved spaces on its streets for persons with disabilities. Reserved parking spaces are only available off-street, in parking lots for shopping centers/malls, office/apartment buildings and college campuses. You can use the state plates and permits to park in designated spaces in those off-street lots. The NYC Department of Transportation also issues a City permit (a rectangular dashboard permit) that allows persons with severe disabilities to park at most curbsides on NYC streets. The New York City parking permit is not valid outside of NYC. To obtain an application for a NYC permit, call (718) 433-3100 or visit the NYC Department of Transportation website: www.nyc.gov/dot u METERED PARKING WAIVERS If you have a certain severe disability that limits your ability to access or put payment into a parking meter, in addition to a mobility-related disability, you may be eligible for a metered parking waiver. The metered parking waiver allows the holder to park in a metered parking space in any city, town or village of New York State without paying the fee. For more information, see forms MV-664.1MP (Application for a Metered Parking Waiver for Persons with Severe Disabilities) and MV-664.2MP (Metered Parking Waiver Information). These forms are available through your local issuing agent and are also available at the DMV website: www.dmv.ny.gov MV-664.1 (8/12) PAGE 2 OF 4 American LegalNet, Inc. www.FormsWorkFlow.com New York State Department of Motor Vehicles Please TEAR at the PERF É APPLICATION FOR A PARKING PERMIT OR LICENSE PLATES, FOR PERSONS WITH SEVERE DISABILITIES and keep pages 1 & 2 for your information. Please read pages 1 and 2 of this packet before completing this application. If applying for a Parking Permit, take the completed application to the issuing agent (local municipality) in the city, town or village where you live. Do not send your application to the Department of Motor Vehicles. DMV does not issue parking permits. Part 1 INFORMATION ABOUT PERSON WITH DISABILITY — (Please print and sign by the arrow.) Last Name First M.I. Telephone No. ( Address: No. and Street Date of Birth Apt. No. o Male o Female I am applying for Do you have license plates for persons with disabilities? ) City State o License Plates (Apply to DMV.) o Parking Permit Zip Code (Apply to local issuing agent.) o Yes - My license plate number is:__________________ o No Read Note on Page 4 Before Signing (Signature of Person with Disability or Signature of Parent or Guardian) — If signed by a parent or guardian, (Date) ç please state your relationship to the person with the disability after your signature. Part 2 MEDICAL CERTIFICATION NOTE: PERMANENT DISABILITIES may be certified by a Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Nurse Practitioner (NP), a Doctor of Podiatric Medicine (DPM, for disabilities related to the foot) or Optometrist (OD, for blindness). TEMPORARY DISABILITIES, however, may be certified only by a Medical Doctor or Doctor of Osteopathy. Check the box(es) that describe the disability, and fill in the diagnosis: o TEMPORARY DISABILITY: A person with a temporary disability is any person who is temporarily unable to ambulate without the aid of an assisting device. Examples of an assisting device include, but are not limited to, a brace, cane, crutch, prosthetic device, another person, wheelchair or walker. IMPORTANT: Temporary permits are issued for six months or less regardless of expected recovery date. Expected Recovery Date:______________________ Diagnosis:_____________________________________________________ What assistive device is needed?_________________________________________________________________________ o PERMANENT DISABILITY: A “severely disabled” person is any person with one or more of the PERMANENT impairments, disabilities or conditions listed below, which limit mobility. Diagnosis:____________________________________________________ Please check the conditions that apply: o o o o o Uses portable oxygen o Legally blind o Limited or no use of one or both legs o Unable to walk 200 ft. without stopping Neuromuscular dysfunction that severely limits mobility o Class III or IV cardiac condition. (American Heart Assoc. standards) Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition Restricted by lung disease to such an extent that forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixty mm/hg of room air at rest Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability, and which imposes unusual hardship in the use of public transportation and prevents the person from getting around without great difficulty. EXPLAIN BELOW HOW THIS DISABILITY LIMITS FUNCTIONAL MOBILITY. ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ MD/DO/DPM/NP/PA/OD Name Professional License No. MD/DO/DPM/NP/PA/OD Address Telephone No. ( ) Read Note on Page 4 Before Signing ç (MD/DO/DPM/NP/PA/OD Signature) (Date) Part 3 FILE INFORMATION (For Issuing Agent Use Only) o Blue o Red Parking Permit No. __________________ Date Issued:_______________ Date Expires:_____________________ o First o Second 9-digit number from NYS Driver License/ID Card ______________________________ o Denied o Revoked Reason:________________________________________________________________ ___________________________________________________________________________________ (Issuing Agent) ç MV-664.1 (8/12) _________________ (Date) (Locality) PAGE 3 OF 4 American LegalNet, Inc. www.FormsWorkFlow.com NOTE TO CUSTOMERS AND MEDICAL PROFESSIONALS Making a false statement or providing false information on an application for a parking permit or license plates for persons with severe disabilities is a crime (a felony or a misdemeanor) under the Vehicle and Traffic Law and the Penal Law, and is punishable by a fine, imprisonment or both, and --regarding applications for parking permits--may also result in liability for payment of a civil penalty of $250-$1,000. Customers Requesting License Plates, or a Parking Permit, for Persons with a Disability By signing Part 1 of this application, you are certifying: l that the information you provide on this application is true; l that you have read and understand the conditions for “Using License Plates and Parking Permits” stated on page 2; and l that you agree to comply with those conditions. Medical Professionals Providing Medical Information in Support of an Application for License Plates, or a Parking Permit, for Persons with a Disability By signing Part 2 of this application, you are certifying: l that the medical information you are providing is true and complete; and l that, in your opinion, the person named in Part 1 of the application is medically qualified to receive license plates, or a parking permit, for persons with a disability, according to the medical criteria specified in Part 2. MV-664.1 (8/12) www.dmv.ny.gov PAGE 4 OF 4 American LegalNet, Inc. www.FormsWorkFlow.com