Application For Disability Placards Form. This is a Ohio form and can be use in Bureau Of Motor Vehicles Statewide.
Tags: Application For Disability Placards, BMV 4826, Ohio Statewide, Bureau Of Motor Vehicles
BMV OR DEPUTY USE ONLY PLACARD NUMBER OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES ISSUE DATE APPLICATION FOR DISABILITY PLACARDS NOTE: A PRESCRIPTION FROM YOUR HEALTH CARE PROVIDER MUST BE SUBMITTED WITH THIS APPLICATION. (Instructions are listed below.) Ohio Revised Code (R.C.) 4503.44 SEE REVERSE SIDE FOR INSTRUCTIONS R.C. 4503.44 allows an applicant to obtain one disability placard. A person with a disability that limits or impairs the ability to walk is entitled to request one additional placard that may be issued at the discretion of the Registrar. Consideration will be given only if the person applies separately for an additional placard and states the reason why the additional placard is necessary. Second placards are issued for an additional fee of $3.50. Please list the reason an additional placard is warranted . INDICATE TYPE OF PLACARD REQUESTED. New Placard - $3.50 Temporary Placard - $3.50 Replacement - $3.50 Original was: Organization transporting disabled persons - $3.50 Damaged Lost Stolen Renewal - $3.50 (Do not apply more than 90 days prior to expiration date.) Previous Placard Number_______________________________ (Applies only to renewal or replacement.) TO BE COMPLETED BY APPLICANT PLEASE PRINT OR TYPE NAME OF DISABLED PERSON SIGNATURE OF DISABLED PERSON, NEXT OF KIN OR CARE PROVIDER X STREET ADDRESS CITY STATE ZIP CODE SOCIAL SECURITY NUMBER OF DISABLED PERSON COUNTY DATE SIGNED TELEPHONE NUMBER CERTIFICATION FOR PRESCRIPTION 1. Cannot walk two hundred feet without stopping to rest. 4. Uses portable oxygen. 2. Cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair or other assistive device. 5. 3. Is restricted by lung disease to such an extent that the person’s 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 millimeters of mercury on room air at rest. 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. 6. Is severely limited in the ability to walk due to an arthritic, neurological, or orthopedic condition. 7. Is blind. THE PRESCRIPTION MUST STATE THE FOLLOWING INFORMATION Original prescriptions required (copies are not accepted) • • • Name of the person with the disability. Indicate you are applying for a disability placard or similar wording. The health care provider must sign and date the prescription. Pursuant to R.C. 4503.44(A)(3), health care provider means “a physician, physician assistant, advanced practice nurse, or chiropractor as defined in this section.” • How long the disability is expected to last. The health care provider must specify an ending date, not to exceed five years, or the prescription will be rejected. Placards expire on the date specified by the health care provider. APPLICATION BY AN ORGANIZATION This is to certify that we are a private organization or corporation or any governmental board, agency, department, division, or office, that, as part of its business or program, transports persons with disabilities (limited or impaired ability to walk) on a regular basis in a motor vehicle that has not been altered for the purpose of providing it with special equipment for use by persons with disabilities. SIGNATURE OF AUTHORIZED AGENT/OFFICER TITLE/POSITION NAME OF ORGANIZATION FEDERAL TAX ID/CHARTER NUMBER X DATE SIGNED STREET ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER SERVICE PROVIDED FOR PERSONS WITH DISABILITIES Warning: Applicant giving false information is subject to prosecution (R.C. 2913.42). BMV 4826 1/11 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com INSTRUCTIONS Note: Placard must be hung on the rear view mirror when the vehicle is parked. Remove placard when driving. APPLICATION REQUIREMENTS: I. TO OBTAIN A PLACARD FOR THE PERSON WITH A DISABILITY A. The application for the parking placard must be completed in the name of the person with a disability and signed. B. Proof of the disability must be submitted. 1. Attach prescription. Prescription must state the name of the person with the disability, and that it is written for a disability placard, state how long the disability is expected to last and must be signed and dated by the health care provider. 2. A veteran must submit a letter on Veteran’s Administration (V.A.) letterhead or a prescription with this application. The letter from the V.A. must state the veteran’s name, percentage of service connected disability, how long the disability is expected to last, and qualifying disabling condition per R.C. 4503.44. C. To apply for a replacement or one additional placard, complete the top portion of this application. A new prescription is not required for replacements or additional placards. Replacement and additional placards expire the same date as the initial placard regardless of issue date. D. Processing fees are $3.50 per placard. Make checks payable to, Ohio Treasurer Josh Mandel. Limit two placards per person. E. Take completed application and fee(s) to any local Deputy Registrar agency or mail to the Ohio Bureau of Motor Vehicles, Attn.: Registration, Remittance Processing Section, P.O. Box 16521, Columbus, OH 43216-6521. For questions or concerns regarding the application process, call (614) 752-7800 or (800) 589-8247. II. TO OBTAIN A PLACARD FOR AN ORGANIZATION A. An organization may obtain a parking placard if it transports individuals with disabilities on a regular basis in a motor vehicle that has not been altered for the purpose of providing it with special equipment for use by persons with disabilities. 1. 2. You may obtain up to two placards per application. 3. If your placard has been lost, stolen, or damaged, complete the bottom portion of this application. List your previous placard number and check the reason for replacement. A replacement placard will expire on the same date as your original placard. 4. B. The bottom portion of the front of this application must be completed in the name of the organization, signed by an officer. Processing fees are $3.50 per placard. Make checks payable to, Ohio Treasurer Josh Mandel. Take completed application and fee(s) to any local Deputy Registrar agency or mail to the Ohio Bureau of Motor Vehicles, Attn.: Registration, Remittance Processing Section, P.O. Box 16521, Columbus, OH 43216-6521. For questions or concerns regarding the application process, call (614) 752-7800 or (800) 589-8247. FINES AND PENALTIES In accordance with R.C. 4511.69, any person parking, stopping or standing a motor vehicle in a special parking space designated properly for persons with disabilities without being operated by or transporting such a person and displaying a disability placard or special license plates is guilty of a misdemeanor. The fine is at least $250.00, but not more than $500.00, is not punishable with imprisonment, and is not a criminal offense. In accordance with R.C. 4731.481 and 4734.23, no health care provider shall furnish a prescription to a person to enable the person to obtain a disability placard or special license plates if they do not meet the criteria in R.C. 4503.44, nor shall any health care provider provide the person with a prescription misrepresenting the expected length of disability. These offenses are misdemeanors of the first degree and are punishable by imprisonment of not more than six months, a fine of not more than $1,000 or both, and sanctions by the State Medical Board, the Chiropractic Examining Board or Board of Nursing respectively. In accordance with R.C. 4503.44, no person or organization shall misrepresent themselves as eligible for a disability placard or special license plates if they are not eligible according to the guidelines of this section. The penalty for this offense is confiscation of the placard or license plates and the revocation of privileges to obtain a disability placard or special license plates. BMV USE ONLY Do not write in space below BMV 4826 1/11 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com