Florida Commission for the Transportation Disadvantaged
605 Suwannee Street, MS-49
Tallahassee, Florida 32399-0450
Phone: 1-800-983-2435
Hearing & Speech Impaired Call: 711 Florida Relay System
Website: www.fdot.gov/ctd
DISABLED TOLL PERMIT RENEWAL FORM
Allow six (6) to eight (8) weeks from the time we receive your completed application for processing.
All completed applications must be MAILED -- NO ELECTRONIC DELIVERIES, THIS INCLUDES EMAIL AND FAX.
APPLICANT INFORMATION
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ORANGE DISABLED TOLL PERMIT NUMBER |
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Orange Permit # |
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APPLICANT DRIVERS LICENSE INFORMATION |
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Florida License # |
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Other State _____ License # |
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APPLICANT VEHICLE INFORMATION |
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Proof of Insurance is REQUIRED - ATTACH A COPY OF YOUR VEHICLE INSURANCE CARD with the APPLICATION
If the vehicle for which this permit was issued is sold, traded or otherwise disposed, I shall be responsible for removing the decal and returning it the Florida Commission for the Transportation Disadvantaged at the above address for a REPLACMENT. If the individual for which this permit was issued is no longer eligible or is deceased, the permit will become null and void and shall be returned to the Florida Commission for the Transportation Disadvantaged at the above address.
I certify that all information I have provided on this application is accurate and I meet the qualifications for a toll permit, as defined in the Beverly Chapman Act, Section 338.155 F.S., on the reverse side. I have provided a disa ility state e t fro either a li e sed physi ia ’s or the Adjudication Office that I do have severe and permanent upper limb mobility or dexterity impairments that substantially impair my ability to deposit coins into coin baskets. I also ertify that I have a valid driver’s li e se a d operate the specially equipped vehicle
listed on this application.
I understand that providing false information to obtain this permit and/or failure to abide by the policies indicated above will result in revocation of all Tolls Permits and Non-Revenue SunPass Transponders and/or possible legal action by the Florida Department of Transportation or appropriate authority.
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Signature of Applicant |
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PHYSICIAN’S/ADJUDICATION OFFICER’S CERTIFICATION
This is to certify that ___________________________________________________ is SEVERELY physically disabled AND has PERMANENT
Applica t’s Na e [PLEASE PRINT]
UPPER LIMB mobility or dexterity impairments, which SUBSTANIALLY IMPAIRS the a ed i dividual’s ABILITY TO DEPOSIT COINS IN TOLL BASKETS, as described in Chapter 338.155, Florida Statutes, see Beverly Chapman Act on reverse side of application.
Signed this ___________ day of _________________________, ___________, by _______________________________________________
Physicia ’s/Adjudicatio Officer’s Na e [PLEASE PRINT]
A licensed physician under Chapter 458 or 459, Florida Statutes, or by the Adjudication Office of the Veterans Administration.
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Signature of Physician/Adjudication Officer |
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PHYSICIAN’S/ADJUDICATION OFFICER’S INFORMATION |
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Medical License Number |
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OFFICIAL USE FOR FLORIDA COMMISSION FOR THE TRANSPORTATION DISADVANTAGED |
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Physician___________________ |
Eligible/Rejected____________________ |
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Permit # _____________ is hereby authorized for use by the Applicant Named above Certified by ____________________________________________
Florida Commission for the Transportation Disadvantaged
TollPermitRenewalForm20161010
Revised 10/10/2016
Florida Commission for the Transportation Disadvantaged
605 Suwannee Street, MS-49
Tallahassee, Florida 32399-0450
Phone: 1-800-983-2435
Hearing & Speech Impaired Call: 711 Florida Relay System
Website: www.fdot.gov/ctd
"Beverly Chapman Act"
(P.L. 88-252)
Section 338.155, F.S.
Payment of toll on toll facilities required; exemptions.
(1)No persons are permitted to use any toll facility without payment of tolls, except employees of the agency operating the toll project when using the toll facility on official state business, state military personnel while on official military business, handicapped persons as provided in this section, persons exempt from toll payment by the authorizing resolution for bonds issued to finance the facility, and persons exempt on a temporary basis where use of such toll facility is required as a detour route. Any law enforcement officer operating a marked official vehicle is exempt from toll payment when on official law enforcement business. Any person operating a fire vehicle when on official business or a rescue vehicle when on official business is exempt from toll payment. The secretary, or the secretary's designee, may suspend the payment of tolls on a toll facility when necessary to assist in emergency evacuation. The failure to pay a prescribed toll constitutes a noncriminal traffic infraction, punishable as a moving violation pursuant to s. 318.18. The department is authorized to adopt rules relating to guaranteed toll accounts.
(2)Any person driving an automobile or other vehicle belonging to the Department of Military Affairs used for transporting military personnel, stores, and property, when properly identified, shall, together with any such conveyance and military personnel and property of the state in his or her charge, be allowed to pass free through all tollgates and over all toll bridges and ferries in this state.
(3) Any handicapped person who has a valid driver's license, who operates a vehicle specially equipped for use by the handicapped, and who is certified by a physician licensed under chapter 458 or chapter 459 or by comparable licensing in another state or by the Adjudication Office of the United States Department of Veterans Affairs or its predecessor as being severely physically disabled and having permanent upper limb mobility or dexterity impairments which substantially impair the person's ability to deposit coins in toll baskets, shall be allowed to pass free through all tollgates and over all toll bridges and ferries in this state. A person who meets the requirements of this subsection shall, upon application, be issued a vehicle window sticker by the Department of Transportation.
(4)A copy of this section shall be posted at each toll bridge and on each ferry.
(5)The Department of Transportation shall provide envelopes for voluntary payments of tolls by those persons exempted from the payment of tolls pursuant to this section. The department shall accept any voluntary payments made by exempt persons.
(6)Personal identifying information provided to, acquired by, or in the possession of the Department of Transportation, a county, or an expressway authority for the purpose of using a credit card, charge card, or check for the prepayment of electronic toll facilities charges to the department, a county, or an expressway authority is exempt from s. 119.07(1) and s. 24(a), Art. I of the State Constitution.
TollPermitRenewalForm20161010
Revised 10/10/2016
