Free MV2162 - Disabled Parking License Plates Application - Wisconsin


File Size: 71.4 kB
Pages: 2
Date: October 27, 2008
File Format: PDF
State: Wisconsin
Category: Government
Author: WisDOT
Word Count: 1,536 Words, 9,652 Characters
Page Size: 1008 x 612 pts
URL

http://www.dot.wisconsin.gov/drivers/forms/mv2162.pdf

Download MV2162 - Disabled Parking License Plates Application ( 71.4 kB)


Preview MV2162 - Disabled Parking License Plates Application
Clear form

Check one:
I would like nonpersonalized Disabled plates. I would like personalized Disabled plates. First Choice
Meaning of First Choice

GENERAL INFORMATION
Only 1 Disabled Parking Identification (DIS ID) Card may be issued to persons with "Disabled" license plates. When using the DIS ID, you MUST keep a copy of this completed application and provide it for inspection upon request by any traffic officer. Make and keep a copy before submitting application to WI DOT. If you currently have valid Permanent (Blue) DIS ID cards, a certification is not required at this time. If you have two (2) cards, one must be returned with this application. The Department may cancel a "Disabled" license plate which was issued as a result of fraud or error or that is used by anyone not authorized. To legally operate your vehicle, you must display license plates within 2 business days of purchase. If you do not have current plates, apply to a DMV Customer Service Center for a standard Disabled plate or an agent authorized by DMV to obtain a temporary plate while your Disabled plate order is processed. An agent may charge a $3 plate fee and/or may also charge a $5 service fee.

DISABLED LICENSE PLATES USE
A motorist who displays disabled license plates on their vehicle: Is exempt from any parking ordinance imposing time limits of one-half hour or more, but is otherwise subject to the laws relating to parking; Can park at a municipally-owned/leased lot without payment in metered spaces when the time limit is one-half hour or more; May park in spaces marked by official traffic signs reserving the space for vehicles displaying VET or DIS plates or DIS ID cards; May obtain, upon request, motor fuel from a full-service pump at the same price as fuel from a self-service pump, if the driver is the person with the disability. This applies at locations where fuel is sold at retail from both full and self-service pumps. The retailer is not required to provide any other service that is not provided to customers who use a self-service pump.

Disabled Parking License Plates
Information and Application
Wisconsin Department of Transportation MV2162

Second Choice
Meaning of Second Choice

Third Choice
Meaning of Third Choice

Choose 1-6 characters. If you choose 6 characters, no spaces are allowed.

A M B U L 8
If you choose 5 characters, you may requestup to 2 spaces between any of the characters. Indicate this request with diagonal lines as shown here.

QUALIFYING PERSONS
A "Disabled" license plate may be issued for a person with a permanent disability that limits or impairs ability to walk, who is the: Owner; Lessee; Regular Attendee of a person with a disability; Employer providing a vehicle; Beneficiary of a trust.

PERSONALIZING INFORMATION

I

M A B L

Use capital letters or numbers. The letter O and the number zero are the same. The following are not acceptable: small letters, symbols, signs, hyphens, apostrophes, etc. Carefully distinguish between: Letters L or I and Number 1 Letter S and Number 5 Letter G and Number 6 Letter Z and Number 2 Letter B and Number 8 Letter U and Letter V Note: If requested personalized plate choices are not available, nonpersonalized Disabled plates will be issued.

A $15 personalized plate fee is required EACH year in addition to the annual registration fee. No refund or adjustment will be made for a change of choice or spacing after the plate has been ordered, or if the application is incorrectly or unclearly completed. The department may refuse to issue OR may recall after issuance, a request which may be offensive to good taste or decency, misleading or conflict with any other license plates. Allow 4-6 weeks for the manufacturing process, after the Certificate of Registration is issued. Disabled cycle plates cannot be personalized.

RELEASE OF NONEXEMPT INFORMATION
The Wisconsin Department of Transportation uses the information on this form to issue disabled parking identification cards and plates. Under open records laws, the Department must make nonexempt information available upon request. Do you want your name withheld from mailing lists of 10 or more individuals?

QUALIFYING VEHICLES
The following vehicles qualify for "Disabled" license plates: Automobiles Motor homes (Annual registration only); A private truck, dual purpose motor home or dual purpose farm truck which has a gross weight of 8,000 pounds or less; A farm truck which has a gross weight of 12,000 pounds or less; Motorcycles (Nonpersonalized only).

Yes.

This will remove your name from marketing lists.

No.

Are you eligible?
Any person certified by an authorized health care specialist as having a permanent disability is eligible for the Disabled Parking License Plates. By legal definition, this includes any person who: Cannot walk 200 feet or more without stopping to rest; Cannot walk without the use of, or assistance from, another person or brace, cane, crutch, prosthetic device, wheelchair or other assistance device; Is restricted by lung disease to the extent that forced expiratory volume for 1 second when measured by spirometry is less than one liter or the arterial oxygen tension is less than 60 mm/hg on room air at rest; Uses portable oxygen; Has a cardiac condition to the extent that functional limitations are classified in severity as class III or IV, according to standards accepted by the American Heart Association; Is severely limited in the ability to walk due to an arthritic, neurological or orthopedic condition.

HOW TO APPLY
1. Complete Applicant Section 2. Have health care provider complete Health Care Certification. (Not required if applicant has valid Permanent DIS ID card) 3. If you request a DIS ID card, you MUST keep a copy of this completed application and provide it for inspection upon request by any traffic officer. Make and keep a copy before submitting application to WI DOT. 4. If you want personalized Disabled plates, mark application and refer to back side of Applicant Section. If you want nonpersonalized Disabled plates, mark application. 5. If the vehicle that you wish to register with Disabled plates is already titled in your name, send the following items: A copy of your Certificate of Registration OR the complete vehicle description on the application; The annual registration fee if the current plates expire within the next 3 months; An additional $15.00 if applying for
personalized plates.
6. If the vehicle is NOT titled in your name, send: A completed title application (MV1 or
MV11);
All required fees, including annual
registration fee;
An additional $15.00 if applying for
personalized plates.
7. Make check or money order payable to: Registration Fee Trust.

Disabled Parking License Plates Application
MV2162 5/2008 s.341.14(1a) Wis. Stats.

Give information for the vehicle that you wish to register with Disabled plates.
Current License Plate Number

APPLICANT SECTION
Check if you would also like 1 Disabled Parking Identification Card (DIS ID).
Registration for Vehicle Owned/Leased by- Check one:

Vehicle Year - Make

Body Type

Vehicle Identification Number

Person with disability. Person who regularly attends person with disability. Print name and sign below. Employer who provides vehicle to person with disability. Print name and sign below. Trust whose beneficiary is person with disability. Complete and attach form MV2790. Sign below.

HEALTH CARE CERTIFICATION
This must be completed and signed by any of the following health care specialists licensed to practice in any state: a physician, a podiatrist, an advanced practice nurse, a chiropractor, a public health nurse or physician assistant who is licensed or certified; or a Christian Science Practitioner residing in Wisconsin. Note: Recertification is required every 4 years.

Please Print Clearly
Legal Name of Person with Disability - First, Middle Initial, Last

Address

Please Print Clearly
City, State, ZIP Code Name of Person Certifying Eligibility

Social Security Number - For Identification Purposes

Address

Month, Day, Year You Were Born

Female Male

City, State, ZIP Code

Driver License/Nondriver Identification Number - If none, write NONE

Medical License Number

Telephone Number Where You May be Reached 7 a.m. - 4:30 p.m.

Area Code and Office Telephone Number

If you have questions about disabled parking license plates: Call: 608-266-3041 FAX: 608-267-5106 E-mail: [email protected] Write to the address shown above.

I have read the information on this form and understand the qualifications and provisions under which "Disabled" license plates may be issued. I authorize my health care specialist to supply the information requested on this form.
(Signature of Person with Disability) (Date)

If you feel the applicant's medical condition or disability may prevent them from exercising reasonable control over a motor vehicle, please contact the Medical Review Unit at 608-266-2327 or refer to http://www.dot.wisconsin.gov/drivers/drivers/ aging/impaired.htm for the reporting process.

AMERICANS WITH DISABILITIES ACT
The Wisconsin Department of Transportation complies with the Americans with Disabilities Act.

If you regularly attend the person with a disability, or are a leasing company or employer print name and sign:
Print Name

8. Mail this application with payment to: Wisconsin Department of Transportation Special Plates Unit - DIS PO Box 7306 Madison WI 53707-7306

I certify that the applicant is permanently disabled according to the conditions specified on this application.

Signature (Authorized Signature of Health Care Specialist) (Date)

Print