STATE OF TENNESSEE
DEPARTMENT OF REVENUE
VEHICLE SERVICES DIVISION 44 VANTAGE WAY, SUITE 160 NASHVILLE, TENNESSEE 37243-8050
APPLICATION FOR DISABLED PERSON LICENSE PLATE AND/OR PLACARD
Application must be completed in the name of the applicant. Please complete all information and sign.
Please check the item requested: |
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______ Permanent Disability Placard |
$21.50 |
______ Temporary Disability Placard |
$10.00 |
______ Renewal Temporary Disability Placard |
$10.00 |
______ Renewal Permanent Disability Placard |
$3.00 |
______ Replacement Placard |
$2.00 |
______ *Disabled Person License Plate (see below)
FIRSTNAME |
MIDDLENAME |
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LAST NAME |
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STREETADDRESS |
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CITY OR TOWN |
COUNTY |
STATE |
ZIP |
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DATE OF BIRTH |
MONTH |
DAY |
YEAR |
Note: If desired, qualified applicants may apply for both a disabled person license plate and a placard.
*For disabled person license plates: The county clerk will collect the necessary fees for the assignment of the disabled person license plate. The exchanged plate must be surrendered to the county clerk before credit can be given.
Tennessee Code Annotated Section 55-21-103(f)(1) required any person who was previously issued a temporary placard to submit a new certification prior to the renewal of the temporary placard. Permanent placard renewals do not require a new certification.
Disabled Person License Plate Requests: Please list your vehicle’s descriptive information below. If your application is only for a placard, it is not necessary to complete this portion.
Description of the vehicle to which plate will be affixed:
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YEAR |
MAKE |
TITLE NUMBER |
VEHICLE IDENTIFICATION NUMBER |
For applicants who are a parent or legal guardian of a permanently disabled individual, please indicate the following: |
Disabled person’s name: |
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Applicant is the person’s (check one): |
Parent |
Legal Guardian |
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Applicant Certification Statement: I, the undersigned applicant, hereby certify under the penalties prescribed in Tenn. Code Ann.
§§55-21-108 and/or 55-21-103, that the statements made herein are true and correct to the best of my knowledge, information and belief.
Applicant’s Signature: |
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Date: |
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Medical Certification: The following section must be completed |
by a medical doctor licensed to practice medicine, a physician’s |
assistance or nurse practitioner acting in conjunction with a written protocol developed jointly by a physician, or a Christian Science Practitioner listed in the Christian Science Journal. This is not required when renewing a permanent placard.
Mechanical device used: |
Crutches |
Braces |
Other (list): |
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Is applicant PERMANENTLY confined to a wheelchair? |
Yes |
No |
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The nature of the disability is: |
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Is the disability permanent |
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or temporary |
? (check one) |
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Certifying Medical Professional or Christian Science Practitioner’s Name: |
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Address: |
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City: |
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State: |
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Zip: |
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Telephone #: |
In accordance with Tenn. Code Ann. §§55-21-103 and 55-21-152, I hereby certify that the disabled individual named in this application has appeared before me and that, in my opinion, he or she meets the requirements of Tenn. Code Ann. §§ 55-21-102(3)(A), (B), and
(C) or 55-21-104(4).
Certifying Medical Professional or Christian Science Practitioner’s Signature: |
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Date: |
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VEHICLE SERVICES DIVISION/COUNTY CLERK USE ONLY |
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Approved By |
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Date Approved |
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Placard Number Assigned |
Expiration Date |
REFERENCE MATERIAL FOR DISABLED PERSON LICENSE PLATE/PLACARDAPPLICATION
Tennessee Code Annotated Sections 55-21-101 through 55-21-108, and 55-21-152
(1)A disabled person is:
•one who is disabled by paraplegia, amputation of leg, foot or both hands, or other condition, certified by a physician duly licensed to practice medicine, resulting in an equal degree of disability (specifying the particular condition) so as not to be able to get about without great difficulty, including impairments that, regardless of cause or manifesta- tion, confine such person to a wheelchair or cause such person to be so ambulatory disabled that he or she cannot walk two hundred feet (200’) without stopping to rest and includes, but is not limited to, those persons using braces or crutches, arthritics, spastics and those with pulmonary or cardiac ills who may be semiambulatory; or
•the owner of a motor vehicle with vision of not more than 20/200 with correcting glasses, or
•the owner of a motor vehicle who is so ambulatory disabled that he or she cannot walk two hundred feet (200’) without stopping to rest and who is seeking treatment and/or healing solely by prayer through spiritual means in the practice of religion in accordance with the creeds or tenets of the First Church of Christ, Scientist in Boston, Massa- chusetts. Such condition shall be certified by a Christian Science practitioner listed in The Christian Science Journal as resulting in a degree of disability so that such person is not able to get about without great difficulty.
(2)One (1) registration and license plate shall be provided free to those disabled persons who are permanently and totally confined to a wheelchair, when so certified by a physician’s statement.
(3)Any owner or lessee of a motor vehicle who is permanently disabled as certified by a physician licensed to practice medicine, a physician’s assistant or nurse practitioner acting in conjunction with a written protocol developed jointly by a physician, or a Christian Science practitioner OR any owner or lessee of a motor vehicle who is the parent or legal guardian of a person who is permanently disabled and who is incapable of operating a motor vehicle, qualifies for a disabled person license plate.
(4)Permanent and temporary placards shall be issued by the participating county clerks.
(5)Permanent placards
•may be issued to persons who are permanently disabled as noted on the physician’s statement;
•may be issued to the parent or legal guardian of a permanently disabled individual;
•shall cost the same as the regular fee for passenger motor vehicles;
•shall expire two (2) years from the date issued.
(6)Temporary placards
•may be issued to persons who are temporarily disabled by a non-ambulatory or semi-ambulatory condition due to surgery, bone fracture or breakage, or similar condition, and whose temporary disabling condition and the estimated duration of such condition is noted on the physician’s statement;
•shall cost $10.00 for the initial placard issuance and subsequent renewals;
•shall be issued for the estimated duration of the condition, but not in excess of six (6) months;
•the use of a “prescription pad” statement can also be used as evidence to determine eligibility for a temporary placard if it is attached to form RV-1310301 and describes the mobility disabilities as “non-ambulatory” or “semi- ambulatory”.
(7)When the recipient of a disabled placard dies, the responsible representative of the deceased shall return the placard(s) to the department of Revenue or the County Clerk’s office.
NOTE: An affidavit must accompany this application when replacing a lost or stolen placard. If the placard is mutilated, the remaining portion of the placard must also accompany the application.
