Florida Toll Exemption: Disabled Toll Permit Renewal Form

Enter your FIRST Name, MIDDLE Name and LAST Name.

Enter the Area Code, the Phone and the Date of Birth [Month, Day, Year].

Enter the Address, Apt. #, City, State and Zip Code.

Enter the Orange Permit # under ORANGE DISABLED TOLL PERMIT NUMBER.

Enter the Florida License # or the Other State and its License #.

Enter the Vehicle Year, Vehicle Make and Model.

Enter the VIN # and the Permanent License Plate #.

Enter Vehicle Registered To. Proof of Insurance is REQUIRED - ATTACH A COPY OF YOUR VEHICLE INSURANCE CARD with the APPLICATION. If vehicle has changed, then proof vehicle was modified with accessibility equipment is REQUIRED - ATTACH A COPY OF PAID ADAPTIVE EQUIPMENT INVOICE with the APPLICATION. If the vehicle for which this permit was issued is sold, traded or otherwise disposed of, you shall be responsible for removing the decal and returning it to the Florida Commission for the Transportation Disadvantaged for a REPLACEMENT. 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. By signing you certify that all information you have provided on this application is accurate and you meet the qualifications for a toll permit, as defined in the Beverly Chapman Act, Section 338.155 F.S., on the reverse side. You have provided a disability statement from either a licensed physician's or the Adjudication Office that you do have severe and permanent upper limb mobility or dexterity impairments that substantially impair your ability to deposit coins into coin baskets. You also certify that you have a valid driver's license and operate the specially equipped vehicle listed on this application. You understand that providing false information to obtain this permit and/or failure to abide by the policies indicated 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.

Sign on the Signature of Applicant line and enter the Date.

Print the Applicant's Name [PLEASE PRINT]: This is to certify that the named individual is SEVERELY physically disabled AND has PERMANENT UPPER LIMB mobility or dexterity impairments, which SUBSTANIALLY IMPAIRS the named individual'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.

The Physician/Adjudication Officer enters the Date on the Signed this day of line, then the Physician's/Adjudication Officer's Name [PLEASE PRINT] after by: A licensed physician under Chapter 458 or 459, Florida Statutes, or by the Adjudication Office of the Veterans Administration.

The Physician/Adjudication Officer signs on the Signature of Physician/Adjudication Officer line and enters the Date.

Enter the Physician's/Adjudication Officer's Name [Last, First, Middle Initial], Medical License Number, State, Area Code and Phone#.

Enter the Physician's/Adjudication Officer's Address, City, State and Zip Code.

Mail the completed application to the Florida Commission for the Transportation Disadvantaged, 605 Suwannee Street, MS-49 Tallahassee, Florida 32399-0450: all completed applications must be mailed, no electronic deliveries, this includes email and fax. Phone: 1-800-983-2435 Hearing & Speech Impaired Call: 711 Florida Relay System. Allow six (6) to eight (8) weeks from the time they receive your completed application for processing.