New York State Department of Motor Vehicles REQUEST FOR PLATES FOR A DISABLED VETERAN NEW YORK 423456 DISABLED VETERAN Veterans who are "severely disabled" as defined in Section 404-a(4) of the Vehicle and Traffic Law, may apply for plates for a Disabled Veteran, entitling them to parking privileges for persons with disabilities. These plates are available from the DMV Custom Plates Unit in Albany. They may be used on any vehicle weighing 6,999 pounds or less (except motorcycles), including vans or pick-up trucks that are not used for commercial purposes. Plate numbers are assigned on a first-come, first-served basis. You cannot select a number yourself. The vehicle on which you will use the plates must be registered in your name. To obtain these plates, fill out page 2 of this form completely and send it to the Custom Plates Unit at the address printed on page 2, along with all of the following items: 1. 2. 3. 4. A completed Vehicle Registration/Title Application (form MV-82). A check or money order payable to the “Commissioner of Motor Vehicles” for $28.75 ($25.00 plate fee + $3.75 plate exchange fee) if you are not paying by credit card. Proof of a service-connected disability. For example, a Certificate of Service Connected Disability (FL-21-802) from the Veterans Administration or DD-214 proving war-time veteran (a copy is acceptable). Proof that you are severely disabled as defined in Section 404-a(4) of the Vehicle and Traffic Law (see below). If you already have plates for the disabled You do not have to provide additional medical certification. Instead, please check the box on page 2 of this form indicating that you already have plates for the disabled and DMV will verify your disabled status. You must still send items 1 - 3 above with your application in order to receive your Disabled Veteran plates. If you do not have plates for the disabled Have a Medical Doctor, Doctor of Osteopathy, Physician Assistant, Nurse Practitioner or Doctor of Podiatric Medicine (if the disability involves podiatry) fill out part 2 of the Application for a Parking Permit or License Plates for Persons with Severe Disabilities (form MV-664.1) and include it with the rest of the items listed above. As an alternative, you may also submit a signed statement from one of the medical professionals listed above on his/her letterhead certifying that you have one or more of the following impairments, disabilities or conditions which are permanent in nature: (a) (b) (c) (d) (e) (f) (g) (h) Uses portable oxygen; Legally blind; Limited or no use of one or both legs; Unable to walk 200 feet without stopping; Neuromuscular dysfunction that severely limits mobility; Class III or IV cardiac condition (American Heart Association standards); Severely limited 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; (i) 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 (the certification must describe the specific impairment, disability or condition and explain how it limits mobility). A certification or statement from an out-of-state Medical Doctor, Doctor of Osteopathy, Physician Assistant or Nurse Practitioner is acceptable for items (a) through (h) if it includes his/her professional license number and the state in which he/she is licensed to practice. Item (i) may only be certified by medical professionals licensed in New York State. Photocopies of certifications and statements where the original certification or statement is less than a year old will be accepted at the discretion of the Custom Plates Unit. NOTE: When you renew your plates for a disabled veteran, you pay only the annual registration fee for the vehicle; there are no additional fees. On the form used to renew your registration, your signature certifies that you are still eligible to receive the plates. You do not have to provide a medical statement when renewing. MV-400PH.1 (4/11) PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com New York State Department of Motor Vehicles REQUEST FOR PLATES FOR A DISABLED VETERAN Please print all information on this form. Enter the following information about the vehicle on which you will use the disabled veteran plates: Current Plate Number DO NOT WRITE IN THIS SPACE (For DMV Use Only) Expiration Date Name in which Vehicle is now Registered Date of Birth / Street Address (Include Street Number and Name and/or Rural Delivery Box No.) City State / Apt. No. Zip Code Daytime Phone (include area code) ( ) o Please check here if you already have plates for the disabled. Payment: Please do not send cash! Check the box below for the payment method you are going to use. A check or money order must be made payable to Commissioner of Motor Vehicles. If you are paying by credit card, provide the credit card information required below and sign on the Authorized Signature line. o Check o Money Order o MasterCard o Visa o Discover o American Express Amount Enclosed $_______________ Name (as it appears on credit card) __________________________________________________________________________ Card Account Number_________________________________________________Expiration Date ______________________ Authorized Signature ç ____________________________________________________________________________________ Send this completed form, and items 1 - 4 listed on page 1 of this form, to: Custom Plates Unit New York State Department of Motor Vehicles PO Box 2775 Albany NY 12220-0775 If you have any questions, please call 1-518-402-4838, or visit DMV on-line at: www.dmv.ny.gov. DO NOT WRITE IN THIS SPACE (For DMV Use Only) MV-400PH.1 (4/11) PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com