Connecticut B-225P Renewable Parking Placard Application

Under Type of Application, check New (1st issue), Replacement or Renewal.

Applicant Is (Check One): Disabled, Blind, Guardian of Blind or Disabled Person, Organization Transporting Blind or Disabled Person or Qualifying Veteran.

Under Identification of Applicant (Please Print), enter the Name of Person Who Is Blind or Disabled (Last, First, Middle Initial), Date of Birth (Required), CT Driver License/ID Card Number (Required) and Daytime Telephone Number.

For a guardian or organization, enter the Guardian or Organization.

Enter the Address and the Mailing Address, each with No. and Street, City or Town, State and Zip Code.

Sign the Signature of Applicant/Parent/Guardian (or Power of Attorney) and enter the Date Signed.

You certify under penalty of false statement that you are blind, or a person who has a disability that limits or impairs the ability to walk, as described in Part B, or a veteran with PTSD and a disability, or you are the parent or guardian of such person and certifying such condition on his or her behalf. If a Power of Attorney is submitted, it must be attached to this application.

The applicant must return this form by mail to State of Connecticut Department of Motor Vehicles Over the Counter Sales Unit 60 State Street, Wethersfield CT 06161-5052, online, or in person at any DMV branch office by appointment. There is no charge for a renewable permit. Before renewal of your permit, the driver's license or non-driver identification card must be renewed.

Criteria to Qualify: the applicant may obtain a placard if they meet one or more of the following conditions, please indicate which condition(s) apply.

The applicant is blind (Must be certified by an optometrist, ophthalmologist or by Board of Education and Services for the Blind (BESB)).

The applicant has a disability that limits or impairs their ability to walk (Must be certified by Physician, Physician Assistant or Advance Practice Registered Nurse (APRN)).

The applicant cannot walk two hundred feet without stopping to rest.

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

The applicant is restricted by lung disease to such an extent that the person's forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixty mm/hg on room air at rest.

The applicant uses portable oxygen.

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

The applicant is severely limited in the ability to walk due to an arthritic, neurological, or orthopedic condition.

The applicant is a veteran with PTSD and a disability that limits or impairs the ability to walk, as defined in # B1 through 6 of Criteria to Qualify (PTSD and veteran status must be certified by a psychiatrist with the U.S. Department of Veterans Affairs-USDVA).

Enter the Certifier's Name (Please print) and check one: Physician, Optometrist, APRN, Ophthalmologist, Physician Assistant, BESB or USVA Psychiatrist.

Enter the Medical License Number (Required) and Medical Licensing State (Required).

Enter the Office Address (No. and Street) (City or Town) (State) (Zip Code) and the Office Telephone Number.

If completed by USDVA psychiatrist, you are also certifying that the person is a veteran as defined in CGS section 27-103(a) and has one or more physical disabilities that limit or impair the ability to walk as defined in #B 1 through 6 of Criteria to Qualify.

Sign the Signature of Physician, PA, APRN, Optometrist, Ophthalmologist, or USDVA Psychiatrist and enter the Date Signed.

The certifier certifies under the penalty of false statement in accordance with sections 14-110 and 53a-157b of the Connecticut General Statutes that the person named in this application meets one or more of the qualifying criteria defined in Criteria to Qualify. I understand that if I make a certification that I know or believe is not true with the intent to mislead the Commissioner, I will be subject to prosecution under the cited laws. The applicant's condition is PERMANENT (Up to 8 years).