Form 32584 – Fill Out and Use This PDF

* This agency is requesting disclosure of your Social Security Number in accordance with IC 4-1-8-1; disclosure is mandatory and this record cannot be processed without it.

Full Name of Veteran

Address (number and street)

I am requesting eligibility determination for the following license plate(s):

Disabled Hoosier Veteran (DHV) –

Include VA Disability Award letter that lists all individual conditions for which you are rated. Purple Heart – Include documentation of award of the Purple Heart Medal.

Ex-POW – Include documentation of POW status.

Once you have completed filling out the requested information above, you may mail or hand deliver this form and supporting documents to IDVA for eligibility determinations.

Along with this form we need the supporting documentation for the license plate(s) you are requesting.

If you are requesting the DHV plate we need your disability award letter from the U.S. Department of Veteran Affairs that shows the individual disability percentages for each rating you received. To be eligible for the DHV plate the veteran must have been rated with one of the following service connected disabilities;

Lost sight in both eyes or suffered permanent impairment of vision in both eyes to the extent of being eligible for service connected compensation for the loss

Suffered loss of one or both feet or the permanent loss of use of one or both feet

Suffered loss of one or both hands or the permanent use of one or both hands

A U.S. Department of Veterans Affairs disability rating for a physical condition that precludes the person from walking without pain or difficulty (this may require a letter from the veteran’s VA doctor if IDVA cannot clearly determine the severity of condition).

Been rated by the United States Department of Veterans Affairs as being at least fifty percent (50%) disabled. At least sixty percent (60%) of that rating must be attributed to one or more mobility disabilities.

If you are requesting a Purple Heart plate you must send proof of award of the Purple Heart Medal.

(You may also request a Purple Heart handicapped plate at your license branch if you are eligible for a handicapped placard in Indiana.)

If you are requesting an Ex-POW plate you must send documentation of your status as a Prisoner of War.

Parking Privileges: The eligible veteran may park at any legal metered space in Indiana and not be charged a fee when displaying any of the plates listed on this form. Additionally the eligible veteran may not be charged a fee when parking in a legally metered space for longer than the time permitted. Parking is not authorized when a metered space is designated as a no parking zone. This privilege is only for the eligible veteran and other states may not recognize this privilege. You must display the universal handicap emblem in order to legally park in a handicap parking space.

DO NOT WRITE BELOW THIS SPACE. TO BE COMPLETED BY INDIANA DEPARTMENT OF VETERANS AFFAIRS.

The above named veteran is eligible for the following license plate(s):