Dmv Form Vsa 54 – Fill Out and Use This PDF

VSA 54 (02/22/2013)

VETERAN

CERTIFICATION OF DISABILITY

Purpose: Veterans use this form to certify to a qualifying disability and to apply for registration fee exemption and special license plates.

Instructions: Send the completed form for validation to Veterans Services Officer, 210 Franklin Road, S.W.

Roanoke, VA. 24011. Submit validated form and your registration application to DMV at the address above.

VETERAN APPLICANT INFORMATION

CHECK THIS BOX TO REQUEST DISABLED VETERAN (DV) PLATES DISPLAYING THE INTERNATIONAL SYMBOL OF ACCESS (DISABLED SYMBOL). MEDICAL PROFESSIONAL CERTIFICATION IS REQUIRED BELOW.

VETERANS ADMINISTRATION USE ONLY

THIS VETERAN IS CERTIFIED DISABLED AS FOLLOWS UNDER PROVISIONS OF VIRGINIA LAW

		Loss of sight, limb(s) or hand(s)		Loss of use of limb(s) or hand(s)			Permanently and totally disabled
VETERANS SERVICES OFFICER NAME (print)					VETERANS SERVICES OFFICER SIGNATURE

PHYSICIAN, PHYSICIAN'S ASSISTANT, NURSE PRACTITIONER CERTIFICATION

This certification may be completed and signed by a Veteran Services physician or the applicant's choice of physician, physician's assistant, nurse practitioner.

Cannot walk 200 feet without stopping to rest.

Uses portable oxygen.

Cannot walk without the use of or assistance from any of the following: another person, brace, cane, crutch, prosthetic device, wheelchair, or other assistive device.

Has a cardiac condition to the exent that functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association.

Is restricted by lung disease to such an extent that forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than 60 millimeters of mercury on room air at rest.

Is severely limited in ability to walk due to an arthritic, neurological or ortheopedic condition

Has been diagnosed with a mental or developmental amentia or delay that impairs judgment including, but not limited to, an autism spectrum disorder.

Has been diagnosed with Alzheimer's disease or another form of dementia.

Is legally blind or deaf.

Other debilitating condition that limits or impairs the ability to walk. SPECIFY CONDITION (required)

Other condition that creates a safety concern while walking because of impaired judgment or other physical, developmental or mental limitation. SPECIFY CONDITION (required)

CHIROPRACTOR, PODIATRIST CERTIFICATION

This certification may be completed and signed by the applicant's choice of chiropractor or podiatrist.

Cannot walk 200 feet without stopping to rest.

Cannot walk without the use of or assistance from any of the following: another person, brace, cane, crutch, prosthetic device, wheelchair, or other assistive device. Is severely limited in ability to walk due to an arthritic, neurological or orthopedic condition.

Other debilitating condition that limits or impairs the ability to walk. SPECIFY CONDITION (required)

MEDICAL PROFESSIONAL CERTIFICATION STATEMENT

I certify and affirm that the veteran applicant identified above has a PERMANENT DISABILITY which limits or impairs his/her ability to walk due to the reason indicated above. I also certify and affirm that all information presented in this form is true and correct, that any documents I have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.

MEDICAL PROFESSIONAL NAME (print )	MEDICAL LICENSE NUMBER		ISSUING STATE	EXPIRATION DATE (mm/dd/yyyy)
MEDICAL PROFESSIONAL SIGNATURE	DATE (mm/dd/yyyy)	OFFICE TELEPHONE NUMBER			OFFICE FAX NUMBER
		(	)		(	)