Form 2769 PDF Details

Form 2769 is an IRS form that taxpayers use to request a six-month extension of time to file their individual income tax return. This form can be used by individuals or organizations, and it must be filed by the original tax filing deadline in order to receive an extension. There are certain eligibility requirements that must be met in order to use this form, so taxpayers should consult with a tax professional if they have any questions. The extension granted by Form 2769 allows taxpayers additional time to file their returns, but it does not extend the time for paying any taxes due.

QuestionAnswer
Form NameForm 2769
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform 2769, form 2769 missouri, missouri handicap placard form, missouri handicap placard physician form

Form Preview Example

MISSOURI DEPARTMENT OF REVENUE

MOTOR VEHICLE BUREAU

PO BOX 598, JEFFERSON CITY MO 65105-0598

(573) 526-3669 www.dor.mo.gov/mvdl

APPLICATION FOR DISABLED PERSON PLACARD

FORM

2769

(REV. 06-2010)

SEE CONDITIONS AND RESTRICTIONS ON REVERSE

TEMPORARY PLACARD

NEW-$2

RENEWAL-$2

REPLACEMENT-$4

PERMANENT PLACARD (NO FEE)

NEW

RENEWAL

REPLACEMENT

RECORD CHANGE ONLY

NAME

ADDRESS

DO YOU CURRENTLY HAVE DISABLED LICENSE PLATE(S)? YES

NO

CHANGE

CHANGE

HOW MANY DISABLED PLACARDS DO YOU CURRENTLY HAVE? ________

 

 

 

 

 

 

 

STATE REASON ADDITIONAL DISABLED PLACARD IS NEEDED IF REQUESTING MORE THAN ONE PLACARD:

 

 

 

 

 

 

 

LEGAL NAME OF DISABLED PERSON (LAST, FIRST, MIDDLE) OR BUSINESS

DATE OF BIRTH

 

 

GENDER

(PLEASE PRINT)

 

 

 

 

 

 

 

 

 

__ __ / __ __ / __ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STREET, RFD, OR PO BOX NUMBER

 

DLN OR FEIN

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

STATE

ZIP CODE

 

__ __ __ __ __

MAIL TO: (IF DIFFERENT THAN ABOVE)

NAME

TELEPHONE NUMBER

(__ __ __) __ __ __ - __ __ __ __

STREET, RFD, OR PO BOX NUMBER

CITY

STATE

ZIP CODE

__ __ __ __ __

CHECK ALL BOXES THAT APPLY:

I hereby certify that I am

A disabled person The parent or guardian of a disabled person

A representative of an agency that transports disabled persons

75 years old or older and am not required to submit a physician’s statement at time of renewal

ANY FALSE STATEMENT IS A VIOLATION OF THE LAW AND MAY BE PUNISHED BY FINE, IMPRISONMENT, OR BOTH. FRAUDULENT APPLICATION, RENEWAL, ISSUANCE, PROCUREMENT, OR USE OF DISABLED PERSON LICENSE PLATES OR WINDSHIELD PLACARDS IS A MISDEMEANOR.

SIGNATURE OF APPLICANT REQUIRED

TELEPHONE NUMBER

(__ __ __) __ __ __ - __ __ __ __

IF REPLACEMENT PLACARD IS REQUIRED, COMPLETE THE FOLLOWING:

REASON REQUIRED

LOSTSTOLEN

MUTILATED

DESTROYED

NEVER RECEIVED (REPLACE AT NO FEE)

NOTARY INFORMATION — NOTARY IS

REQUIRED FOR REPLACEMENTS ONLY

STATE

 

 

 

 

 

SUBSCRIBED AND SWORN BEFORE ME THIS

 

 

 

 

 

 

 

 

 

DAY OF

 

NOTARY PUBLIC NAME (TYPED OR PRINTED)

 

NOTARY PUBLIC SIGNATURE

 

MY COMMISSION

 

 

 

 

 

 

 

 

 

 

EXPIRES

 

 

 

 

 

 

 

 

 

 

 

NOTARY PUBLIC EMBOSSER SEAL OR STAMP

 

COUNTY (OR CITY OF ST. LOUIS)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

USE RUBBER STAMP IN CLEAR AREA BELOW

 

 

 

 

 

 

 

 

 

 

 

FOR OFFICE USE ONLY

 

 

 

 

 

 

PREVIOUS PLACARD NO.

 

 

EXPIRATION DATE

FEE

SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

__ __ / __ __ / __ __ __ __

 

 

 

 

FEE

 

 

 

 

 

 

 

 

 

GOOD CAUSE FOR ADD’L PLACARD

 

 

 

 

 

 

 

 

NEW PLACARD NO.

 

 

EXPIRATION DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTARY (REPLACEMENT ONLY)

 

 

 

__ __ / __ __ / __ __ __ __

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF PHYSICIAN’S STATEMENT

__ __ / __ __ / __ __ __ __

APPROVED BY

MO 860-1674 (06-2010)

REQUIREMENTS

Submit the following items:

1.This completed and signed application.

2.Physician’s Statement for Disabled Person Placard (DOR-1776) Note: Any not-for-profit group, organization, or other entity that transports physically disabled persons must submit a statement on business letterhead, signed by an officer that states the entity transports physically disabled persons. The Physician’s Statement must be issued within 90 days of the application date. The Physician’s Statement for Disabled Person Placard (DOR-1766) is not required to obtain a replacement placard. A Physician’s Statement is required every four years for renewal applicants under the age of 75.

3.A $2 fee for each temporary placard or $4 fee for each temporary replacement placard. (There is no fee for new, renewal, or replacement permanent placards.)

You may submit the items above to your local license office or by mail to the following address.

MOTOR VEHICLE BUREAU

PO BOX 598

JEFFERSON CITY MO 65105-0598

Upon approval of your application, you will receive a new placard and a validated registration receipt. Keep the registration receipt with you when using the placard.

PERMANENT/TEMPORARY DISABLED PERSON PLACARD INFORMATION

A permanent/temporary disabled person placard (placard) is a removable windshield placard that is to be hung from the front, middle rearview mirror of a PARKED vehicle in order to park in disabled parking spaces. It is unlawful to hang the placard from the rearview mirror when driving the vehicle. Designated disabled parking spaces may only be used and the placard only displayed when a physically disabled person is the occupant of the motor vehicle when the vehicle is parked (or immediately before it is parked) or when the vehicle is being used to pick up or drop off the physically disabled person who was issued the placard. The driver or any occupant shall produce the VALIDATED RECEIPT of this application and photo identification of the disabled person for whom the placard was issued upon request from any law enforcement or peace officer. Failure to do so is a class A misdemeanor. A placard is not transferable to another person. It is unlawful for the placard owner to loan the placard to any person for any reason, even if that person is disabled.

Who qualifies for a permanent/temporary disabled person placard?

Any physically disabled person, parent or guardian of a physically disabled person, or a not-for-profit group or organization that transports physically disabled persons.

What is the definition of “physically disabled?”

The term “physically disabled” means a blind person, as defined in Section 8.700, RSMo, or a person with medical disabilities which prohibits, limits, or severely impairs one’s ability to walk, as determined by an

advance practice registered nurse, licensed physician, chiropractor, physician’s assistant, podiatrist, or optometrist as follows.

1.The person cannot walk 50 feet without stopping to rest due to a severe and disabling arthritic, neurological, orthopedic condition, or other severe and disabling condition;

2.The person cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device;

3.The person is restricted by a respiratory or other disease to such an extent that the person’s forced respiratory volume for one 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;

4.The person uses portable oxygen; or

5.The person has a cardiac condition to the extent that the person’s functional limitations are classified in severity as Class III or Class IV according to the standards set by the American Heart Association.

A person’s age shall not be a factor in determining whether such person is physically disabled.

Who determines physical disability?

An advance practice registered nurse, licensed physician, chiropractor, physician’s assistant, podiatrist, or optometrist must certify the person is permanently or temporarily “physically disabled” by completing a Physician’s Statement for Disabled Person’s Placard (DOR-1776) and indicating whether the disability is permanent or temporary.

What are the penalties for misuse, fraudulent application, renewal, procurement, or use of a permanent/ temporary disabled person placard?

Fraudulent application, renewal, procurement, or use of a placard, or parking in a disabled parking space by a person not physically disabled or transporting a physically disabled person is a misdemeanor.

Should the permanent/temporary disabled person placard be returned to the Department of Revenue if the placard owner is deceased?

Yes, the personal representative of the deceased or the person who has possession of the placard must return the placard to the Department of Revenue. Failure to return the placard is a misdemeanor.

If you have any questions, visit our web site at www.dor.mo.gov/mvdl or call (573)฀526-3669.

MO 860-1674 (06-2010)

DOR-2769 (06-2010)

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This form will require specific details; in order to guarantee correctness, you need to bear in mind the following guidelines:

1. Complete the handicap placard missouri with a number of necessary blanks. Note all the information you need and be sure there is nothing left out!

Stage # 1 for completing form 2769

2. Your next step is usually to fill in the following fields: CITY, CHECK ALL BOXES THAT APPLY, I hereby certify that I am, STATE, ZIP CODE, A disabled person, The parent or guardian of a, A representative of an agency that, years old or older and am not, ANY FALSE STATEMENT IS A VIOLATION, SIGNATURE OF APPLICANT REQUIRED, TELEPHONE NUMBER, IF REPLACEMENT PLACARD IS REQUIRED, LOST, and STOLEN.

TELEPHONE NUMBER, A disabled person, and years old or older and am not inside form 2769

A lot of people often make some errors while filling in TELEPHONE NUMBER in this part. Ensure that you review what you type in right here.

3. This next segment is considered pretty simple, NEW PLACARD NO, EXPIRATION DATE, DATE OF PHYSICIANS STATEMENT, APPROVED BY, FEE, GOOD CAUSE FOR ADDL PLACARD, and NOTARY REPLACEMENT ONLY - all of these form fields must be filled out here.

Completing segment 3 in form 2769

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