Are you expecting a tax refund this year? If so, be sure to e-file your return using Form 543. This form is used to report payments made to employees who are not covered by Social Security or Medicare. By using Form 543, you can ensure that the government has all the information it needs to accurately process your return. For more information on how to use this form, consult the instructions provided below.
| Question | Answer |
|---|---|
| Form Name | Form 9400 543 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 9400543 wi form 9400 543 |
State of Wisconsin |
Class A Disability Permit Application |
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Department of Natural Resources |
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dnr.wi.gov |
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Check here if renewal. Previous Permit Number:
An initial Class A permit is valid for the
Upon renewal, a Class A permit is valid for the
Notice: Use of this form is required by the DNR for any application filed pursuant to s.29.193, Wis. Stats. The DNR will not consider your application unless you complete and submit this form. Personally identifiable information provided may be used to determine identity of the applicant, participation in natural resources surveys, eligibility for approvals and other enforcement purposes. The Department may provide this information to requesters as required by Wisconsin's Open Records law [ss.
LEAVE
Permit Number |
Date Issued |
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Expiration Date |
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Customer ID Number |
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Application must be filled out completely.
SECTION I - TO BE COMPLETED BY APPLICANT (Please type or print legibly)
Applicant's Name
Driver's License Number
DNR Customer ID Number
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Home Phone Number (incl. area code) |
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City, State, ZIP Code |
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County of Residence |
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Date of Birth (Mo. - Day - Year) |
Color Eyes |
Color Hair |
Weight |
Height |
Sex |
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Male |
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Female |
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I hereby certify that the above information is true and correct, and I hereby authorize the Department of Natural Resources to examine all medical records regarding my physical disability.
Applicant's Signature
Date Signed
SECTION II - TO BE COMPLETED BY LICENSED PHYSICIAN OR CHIROPRACTOR
NOTE: Applicant must be disabled to the extent described on the back of this form to be eligible for a permit to shoot or hunt from a stationary vehicle. Please check the box that best answers each question for a Class A permit.
A. MOBILITY (Licensed Physician or Chiropractor)
1. Does applicant have a permanent or irreversible physical disability? . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Which of the following does applicant require for mobility?
a. Wheel chair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
b. Walker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c. One leg brace or external prosthesis above the knee. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d. Two leg braces or external prostheses below the knees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
e. Two crutches or two canes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Is applicant able to ambulate without any of the above (2a - 2e)? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Will the applicant's need for any of the above (2a - 2e) be permanent? . . . . . . . . . . . . . . . . . . . . . . . . . .
B. LUNG DISEASE (Licensed Physician)
Does applicant suffer from lung disease to the extent that: (1) forced expiratory volume for one second when measured by spirometry is less than one liter, or (2) the arterial oxygen tension is less than 60 millimeters of mercury on room air at rest? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
C. CARDIOVASCULAR DISEASE (Licensed Physician)
Does applicant suffer from cardiovascular disease to the extent that functional limitations are
classified in severity as Class 3 or 4 according to standards accepted by the American Heart Assoc.? . . . .
Name of Physician or Chiropractor (Please Print) |
Medical License Number |
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Date Signed |
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Signature of Physician or Chiropractor |
Phone Number (include area code) |
Fax Number (include area code) |
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Address |
Mail Application To: |
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Department of Natural Resources |
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Disabled Permit Applications - CS 1 |
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City, State, ZIP Code |
PO Box 7924 |
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Madison, WI 53707 |
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(please allow 6 weeks for review and processing) |
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29.193 Approvals for disabled persons. (1) TROLLING PERMITS. (a) The department shall, after an investigation and without charging a fee, issue a trolling permit to any person who meets the requirements under s. 29.171(3)(a) 2. or 4. [s. 29.171(4) (a)
2.or 4.]
(b)A person holding a current fishing license issued under this chapter and either a trolling permit issued under par. (a) or a Class A permit issued under sub. (2) may fish or troll in the waters of this state using an electric motor, notwithstanding any ordinances enacted under s. 30.77(3) that prohibit the use of motor boats on navigable waters and subject to rules promulgated by the department regarding the use of electric motors for fishing or trolling by disabled persons.
(2)HUNTING PERMITS. (a) Definitions. As used in this subsection:
1."Accompanied" means being subject to continuous visual or voice contact without the aid of any mechanical or electronic amplifying device other than a hearing aid.
5."Visually handicapped" means blind, as defined in s. 47.01(1).
(b)Issuance of permit. 1. The department shall, after investigation and without charging a fee, except for the costs of review in par. (c) 3. or (e), issue a Class A, Class B or Class C permit to any person, as provided in this subsection.
2.An applicant shall submit an application on a form prepared and furnished by the department, which shall include a written statement or report prepared and signed by a licensed physician or licensed chiropractor, prepared no more than 6 months preceding the application and verifying that the applicant is physically disabled.
3.As part of the application for a Class A or Class B permit under this subsection, the applicant shall authorize the department by written release to examine all medical records regarding the applicant's physical disability.
(c)Eligibility. 1. The department shall issue a Class A permit under this subsection to an applicant who is permanently disabled, as determined by the department, in any of the following ways:
a.Has a permanent or irreversible physical disability, is unable to ambulate and requires a wheelchair, walker, one leg brace or external prosthesis above the knee, 2 leg braces or external prostheses below the knees, 2 crutches or 2 canes for mobility.
b.Suffers significantly from lung disease, to the extent that forced 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.
c.Suffers significantly from cardiovascular disease, to the extent that functional limitations are classified in severity as class 3 or 4, according to standards accepted by the American heart association on May 3, 1988, and where ordinary physical activity causes discomfort, fatigue, palpitation, dyspnea or anginal pain.
2.The department shall issue a Class B permit under this subsection to an applicant who has a temporary disability which restricts mobility or ambulation due to injury or operative procedures and who either has a leg, hip or back, or any part thereof, casted by a licensed physician due to a fracture or has leg, hip or back surgery.
2m. The department may issue a Class B permit under this subsection to an applicant who has a temporary disability which restricts mobility or ambulation due to illness, injury or operative procedures.
Class A Disability Permit Application
Form |
Page 2 of 2 |
3.The department may issue a Class B permit to an applicant who is ineligible for a permit under subd. 1., 2. or 2m. or who is denied a permit under subd. 1., 2. or 2m. if, upon review and after considering the physical condition of the applicant and the recommendation of a licensed physician or licensed chiropractor selected by the applicant from a list of licensed physicians and licensed chiropractors compiled by the department, the department finds that issuance of a permit complies with the intent of this subsection. The use of this review procedure is discretionary with the department and all costs of the review procedure shall be paid by the applicant.
4.The department shall issue a Class C permit to any person who is visually handicapped.
(cg) Approval required. In order to hunt, fish or troll after receiving a permit under this section, the permit holder must apply for and be issued, or must already hold, any type of approval required under this chapter for the type of hunting or fishing that he or she will be doing.
(cr) Authorization. 1. A person holding a current resident or nonresident deer hunting license and a Class A or Class C permit may hunt deer of either sex with a firearm during any season open to hunting of deer with firearms that is established by the department.
2.A Class A permit authorizes the holder to shoot or hunt from a stationary vehicle, to fish or troll as authorized under sub.(8m)(b) [sub. (1)(b)] and to hunt certain game with a crossbow as authorized under ss. 29.103(2)(ar), 29.104(2) and 29.117(2).
[ss. 29.164 (2)(b) , 29.171(2) and 29.216(2)]
3.A Class B permit authorizes the holder to use any of the hunting or fishing methods authorized in this chapter for a holder of a Class A permit that are specifically approved by the department for that Class B permit holder upon issuance or subsequent modification of the Class B permit.
(d)Assistance. 1. A holder of a Class A or Class B permit may be accompanied by a person who is not eligible to apply for a Class A or Class B permit. The accompanying person may not hunt or carry a firearm, bow or crossbow unless that person has been issued the appropriate approval to do so. The assistance rendered by an accompanying person who has not been issued the appropriate approval is limited to field dressing, tagging and retrieving game for the permit holder.
2. A holder of a Class C permit shall be accompanied by a person who is not eligible to apply for a permit under this section. The accompanying person may not hunt or carry a firearm, bow or crossbow unless the person has been issued the appropriate approval to do so. The assistance rendered by an accompanying person may include sighting the firearm, bow or crossbow, identifying the game and field dressing, tagging and retrieving game for the permit holder.
(e)Review of decisions. An applicant denied a permit under this subsection, except a permit under par. (c) 3., may obtain a review of that decision by a licensed physician or a licensed chiropractor designated by the department and with an office located in the department district in which the applicant resides. The department shall pay for the cost of a review under this paragraph unless the denied application on its face fails to meet the standards set forth in par. (c) 1. or 2. A review under this paragraph is the only method of review of a decision to deny a permit under this subsection and is not subject to further review under ch. 227.