OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES GRATIS APPLICATION FOR REMOVABLE WINDSHIELD PLACARD FOR PERSONS WITH DISABILITIES (See instructions on reverse side) APPLICANT’S INFORMATION (Please print or type) QUALIFICATIONS FOR REMOVABLE WINDSHIELD PLACARD An individual qualifies for a “Removable Placard for Persons with Disabilities” if that disability limits or impairs the ability to walk as determined by a physician, chiropractor, or advanced practice nurse (O.R.C. 4503.44). Attach the required certification (listed on next page) to this application for processing. The disability must meet at least one of the following criteria: SECTION A: Indicate in the box(es) provided to the left of each of the 7 qualifications which one(s) of the qualifications you meet with an X. 1. Cannot walk two hundred feet without stopping to rest; 2. Cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device; 3. Is restricted by a 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; 4. Uses portable oxygen; 5. 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. WHAT IS YOUR SPECIFIC DISABLING CONDITION? SECTION B: NAME OF DISABLED PERSON STREET ADDRESS SOCIAL SECURITY NUMBER CITY STATE ZIP CODE OH SIGNATURE OF DISABLED PERSON OR NEXT OF KIN/RELATIONSHIP PHONE NUMBER X ( ) Second placards are available for definable needs. If you wish to apply for a second placard, please state the need: Contact this office at (614) 752-7518 for more information or go to www.ohiobmv.com RETURN TO: Ohio Bureau of Motor Vehicles, PO Box 16521, Attn: Gratis Unit, Columbus Ohio 43216-6521 BMV 4531 7/07 Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com INSTRUCTIONS: 1. SIGN: Application must be completed in the name of the disabled person, including signature. (Section B). 2. QUANTITY: Applicant may obtain a second placard if a definable need is listed. (Section B). 3. CERTIFICATION REQUIRED: DISABLED VETERANS must complete Section A and B and include a current letter from the Department of Veterans Affairs stating that your disability is one defined in ORC 4503.44. If you need to contact the Department of Veterans Affairs, the toll free number is 1-800-827-1000. ACTIVE DUTY MILITARY MEMBERS must complete Section A and B, provide proof of active duty status, and one of the following: current Department of Defense convalescent leave statement, Department of Defense document indicating that the person currently has an ill or injured casualty status or has limited duties, or a prescription from any physician, chiropractor or advance practice nurse prescribing the placard for the applicant. 4. PAYMENT: NO FEE FOR DISABLED VETERANS OR DISABLED ACTIVE DUTY MILITARY MEMBERS. 5. RETURN PROMPLTY: Applicants may take completed application to any local Deputy Registrar Agency or mail to the Ohio Bureau of Motor Vehicles/Gratis Unit, P.O. Box 16521, Columbus, Ohio 43216-6521. For additional information, call: Gratis Unit 614-752-7518 6. FINES AND PENALTIES: In accordance with ORC section 4511.69, any person stopping, standing or parking a motor vehicle in a special parking space designated for persons with disabilities without being operated by or transporting such a person and displaying a disability placard or special license plate 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 ORC section 4731.481 and 4734.161, no physician or chiropractor respectively shall furnish a prescription to a person to enable the person to obtain a disability placard or special license plate if they do not meet the criteria in ORC section 4503.44, nor shall any physician or chiropractor 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 not more than $1,000, or both, and sanctions by the State Medical Board or the Chiropractic Examining Board respectively. In accordance with ORC section 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 4531 7/07 Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com