Form B 225 PDF Details

Fulfilling a crucial need within Connecticut's community, the B 225 form serves as a key tool for individuals with disabilities or impairments, facilitating their access to special parking privileges and thereby enhancing their mobility and independence. This comprehensive document, overseen by the Connecticut Department of Motor Vehicles, outlines a structured process for applying for, renewing, or replacing special parking permits. Applicants are required to verify their eligibility by including personal identification details and obtaining a medical professional's certification of their impairment. The inclusivity of the form is evident in its accommodation for a range of professionals - from physicians and physician assistants to optometrists and the Board of Education and Services for the Blind - to validate the applicant's condition. Moreover, the form underscores the importance of accuracy and honesty, with stipulations that any attempt to provide false information could lead to legal repercussions. The provisions for both temporary and permanent impairment cater to the diverse needs of Connecticut's residents, ensuring that those who face mobility challenges are afforded the support they need to navigate their communities with ease.

QuestionAnswer
Form NameForm B 225
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesAPRN, false, connecticut special permit application and impairment certificate, USVA

Form Preview Example

DMV

NEW

PERMIT NUMBER(S)

PLATE NUMBER

 

MO.

YEAR

USE

 

 

EXPIRES

 

 

 

 

 

 

 

ONLY

REPLACEMENT

 

 

 

 

 

SPECIAL PERMIT APPLICATION

STATE OF CONNECTICUT

AND IMPAIRMENT CERTIFICATE

DEPARTMENT OF MOTOR VEHICLES

B-225 REV. 11-2011

HANDICAPPED UNIT

60 STATE STREET, WETHERSFIELD, CT 06161-5056

 

 

On The Web At ct.gov/dmv

 

Telephone: (860) 263-5154

INSTRUCTIONS:

Fax: (860) 263-5556

dmv.hpapp@ct.gov

NEW:

 

1.PART A must be completed by applicant. Applicant must have a Connecticut Driver License or ID card.

NOTE: If impairment is blindness and you hold a valid Connecticut Driver License, the license must be surrendered at a full service office of the Department of Motor Vehicles when special permit application is submitted. For purpose of identification, a non-driver photo ID may be obtained in place of the Driver's License.

PART B must be completed and signed by a physician, APRN, physician's assistant or USVA. An optometrist, ophthalmologist or the Connecticut Board of Education and Services for the Blind may complete PART B in case of visual impairment. Stamped signatures are not permissible.

If PART A and PART B are not completed in full, the application will be returned and the special permit will not be issued.

REPLACEMENT: New style only - complete PART A.

2.The applicant must return this form by mail to the address above, in person at any DMV branch office, or via fax or e-mail. There is no charge for a permanent permit, however, there is a $5.00

charge for temporary permits. (Temps cannot be faxed or e-mailed)

NOTE: Only one (1) permit will be issued/allowed in connection with a single disabled person.

VALIDATED BY DMV ABOVE

PART A - COMPLETED BY APPLICANT

TYPE OF APPLICATION

NEW (1st issue)

REPLACEMENT

RENEWAL

APPLICANT IS (Check One)

 

PERSON WHO IS DISABLED

PERSON WHO IS BLIND

 

ORGANIZATION TRANSPORTING BLIND OR

 

 

DISABLED PERSON

 

 

 

 

 

 

 

 

 

 

 

NAME OF PERSON WHO IS BLIND OR DISABLED (Last, First, Middle Initial)

 

 

IDENTIFICATION

 

 

 

 

 

OF

DATE OF BIRTH (Required)

DRIVER LICENSE/ID CARD NUMBER (Required)

 

DAYTIME TELEPHONE NUMBER

 

 

 

 

 

APPLICANT

 

 

 

 

 

(Please Print)

 

 

 

 

 

ADDRESS (No. and Street)

 

(City or Town)

(State)

(Zip Code)

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (No. and Street)

(City or Town)

(State)

(Zip Code)

 

 

 

 

 

I, the person who is blind or disabled or the parent or guardian of such person do hereby declare, under penalty of false statement, that the visual acuity or the

APPLICANT'S

ability to walk of the above named person is seriously impaired as specified.

 

 

SIGNATURE OF APPLICANT

 

 

 

DATE SIGNED

SIGNATURE

 

 

 

 

 

 

 

 

X

PART B - COMPLETED BY PHYSICIAN, APRN, PHYSICIAN'S ASSISTANT, OPTOMETRIST, OPHTHALMOLOGIST, BESB OR USVA

PHYSICIAN'S, APRN'S,

OPTOMETRIST'S OR OPHTHALMOLOGIST CERTIFICATION OF DISABILITIES AS DEFINED IN

23CFR

PART 1235.2

I hereby certify that the above named applicant is blind or has disabilities that limit or impair their ability to walk, and that his or her condition is:

PERMANENT (UP TO 6 YEARS)

TEMPORARY (6 MONTHS OR LESS)

CERTIFIER'S NAME (Please print)

CHECK ONE

 

 

BESB

PHYSICIAN'S ASSISTANT

PHYSICIAN

APRN

OPTOMETRIST

USVA

OPHTHALMOLOGIST

MEDICAL LICENSE NUMBER (Required)

MEDICAL LICENSING STATE (Required)

OFFICE ADDRESS (No. and Street)

(City or Town)

(State)

(Zip Code)

OFFICE TELEPHONE NUMBER

ADDITIONAL CERTIFICATION MAY BE REQUIRED AT THE TIME OF THE ORIGINAL APPLICATION OR ANY TIME THEREAFTER IF THERE IS CAUSE TO BELIEVE THAT THE ABILITY TO WALK IS NOT SERIOUSLY AND PERMANENTLY IMPAIRED.

PHYSICIAN'S, APRN'S,

OPTOMETRIST'S OR

OPHTHALMOLOGIST'S

STATEMENT AND

SIGNATURE

SIGNATURE OF PHYSICIAN, APRN, OPTOMETRIST OR OPHTHALMOLOGIST

DATE SIGNED

X

The information provided to the Commissioner of Motor Vehicles herein is subscribed by me, the undersigned, under penalty of false statement, in accordance with the provisions of Section 14-110 and 53a-157b of the Connecticut General Statutes. I understand that if I make a statement which I do not believe to be true with the intent to mislead the Commissioner, I will be subject to prosecution under the above-cited laws.

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How to fill out B-225 step 1

2. After finishing this step, go to the subsequent stage and enter the essential details in all these fields - OPTOMETRISTS OR OPHTHALMOLOGIST, CERTIFICATION OF DISABILITIES AS, CFR, PART, I hereby certify that the above, PERMANENT UP TO YEARS, TEMPORARY MONTHS OR LESS, CERTIFIERS NAME Please print, CHECK ONE, PHYSICIANS ASSISTANT, BESB, USVA, MEDICAL LICENSE NUMBER Required, MEDICAL LICENSING STATE Required, and PHYSICIAN.

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