STATE OF NEW HAMPSHIRE
DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES JAMES H. HAYES SAFETY BUILDING 10 HAZEN DRIVE, CONCORD, NH 03305
APPLICATION
FOR
WALKING DISABILITY
PRIVILEGES
Check Items Required:
___ Hanging Placard
___ Walking Disability Plates
___ Walking Disability Vanity Plates
THIS APPLICATION IS FILED PURSUANT TO THE APPLICABLE PROVISIONS OF NH RSA 261:88
(Refer to Eligibility Requirements On Reverse Side)
LAST NAMEFIRST NAMEMIDDLE NAME
INDIVIDUAL |
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APPLICANTS |
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TELEPHONE # (OPTIONAL) |
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MUST |
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COMPLETE |
CITY OR TOWN |
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STATE |
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ZIP CODE |
THIS |
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SECTION |
MONTH |
DAY YEAR |
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PLATE NO. |
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PLATE TYPE |
MFG. YR. |
MODEL |
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E |
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DOB: |
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I, the undersigned applicant, certify under penalty of unsworn falsification pursuant to RSA 641:3, that I am a resident of this State qualified for Walking Disability Privileges or that I provide primary transportation for the named applicant, as a member of that relative’s household.
APPLICANT’S SIGNATURE: DATE:
THIS CERTIFICATION MUST BE COMPLETED BY A MEDICAL DOCTOR
I certify, under the penalty of perjury, that the person whose name appears is under my treatment and care and in my professional opinion has a walking disability as defined under RSA 259:124.
The condition is: |
PERMANENT TEMPORARY: |
for a period of Months |
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(Not to exceed six months) |
Brief Description of walking disability: ___________________________________________________________________________
PHYSICIAN’S SIGNATURE |
M.D. DATE |
PHYSICIAN’S NAME (PRINT LEGIBLY) |
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ADDRESS |
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ORGANIZATIONS
COMPLETE
THIS
SECTION
l/We certify, under penalty of unsworn falsification pursuant to RSA 641:3, that the business identified herein is owned by an organization in the private or public sector that is primarily engaged in a business in this state involving care, treatment, rehabilitation or transportation of persons with walking disabilities.
Business Name:
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Signature of ApplicantTelephone#
LAST NAME |
FIRST NAME |
MIDDLE NAME |
VEHICLE OWNER
PRINT
FULL ADDRESS
STREET ADDRESS OR RFD AND BOX NO.
CITY OR TOWN |
COUNTY |
STATE ZIP CODE |
VEHICLE OWNER’S DATE OF BIRTH
WALKING DISABILITY PLATES |
WALKING DISABILITY VANITY PLATES WALKING DISABILITY PLACARD NO. |
ISSUED:
GENERAL INSTRUCTIONS:
WALKING DISABILITY PLATES, VANITY PLATES, AND REMOVABLE HANGING PLACARDS
WALKING DISABILITY PLATES: If you have a permanent disability that qualifies you for Walking Disability Privileges, you may apply for walking disability plates containing the international accessibility symbol and a distinguishing number. An exchange of the plates you may currently hold may be made at the central office in Concord. A fee of $5.00 is required.
WALKING DISABILITY VANITY PLATES: If you have a permanent disability that qualifies you for Walking Disability Privileges, you may apply for vanity plates containing the international accessibility symbol and such letter and numbers as may be available for such plates. The fee shall be $30.00 in addition to the normal registration fee for such vehicle.
HANGING PLACARDS: An applicant who qualifies for walking disability plates may apply for a removable windshield placard containing the international accessibility symbol. Those with permanent disabilities shall be issued a blue placard with white lettering. The placard shall be removed from the rear-view mirror when the vehicle is in motion.
HANGING PLACARDS - (TEMPORARY): An applicant with a temporary walking disability is not entitled to walking disability plates but may be issued a removable windshield placard containing the international accessibility symbol which shall be a red placard with white lettering and shall not be valid for more than a six (6) month period.
DEPENDENT TRANSPORTATION: Walking disability plates, or a permanent or temporary hanging placard may be issued for use on a vehicle owned by a relative of a person with a walking disability, if the vehicle owner is a resident of this state, a member of that relative’s household and the disabled person is dependent on the vehicle owner as his/her primary means of transportation.
QUALIFYING ORGANIZATION: Walking disability plates, vanity plates or hanging placards may be issued for use on motor vehicles owned by an organization the private or public sector that is primarily engaged in a business in this state involving care, treatment, rehabilitation, or transportation of persons with walking disabilities.
DEFINITION OF WALKING DISABILITY: ‘‘Walking Disability”, as used in RSA 261:88 (c) means a disability which limits or impairs a person’s ability to walk, as determined by a licensed physician, to such an extend that such person:
I.Cannot walk without the use of, or assistance from, brace, cane, crutch, another person, prosthetic device,
wheelchair, or other assistance device; or
II.Is restricted by lung cancer to such an extent that the person’s forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one (1) liter, or the arterial oxygen tension is less than 60
mm/hg on room air at rest; or III. Uses portable oxygen; or
IV. Has a cardiac condition to the extent that the person’s functional limitations are classified in severity as class 3 or class 4 according to the standards set by the American Heart Association; or
V.Is severely limited in the ability to walk due to an arthritic, neurological, orthopedic, or other medically disabled condition.
PARKING PRIVILEGES FOR PERSONS WITH WALKING DISABILITY: (RSA 265:74) Any motor vehicle carrying the special plates or hanging windshield placard issued to a person with a walking disability under RSA 261:88, or a similar license plate or card issued by another state or country displaying the international accessibility symbol shall be allowed free parking in any city of town, including any state or municipal parking facility where a fee is charged. Each city or town shall have the discretion to set the time periods using guidelines which shall be provided by the governor’s commission on disability. The free parking shall only be allowed if the person who qualifies for the special plates or hanging placard is being transported in the vehicle to or from the parking place.
SPECIAL NOTE TO APPLICANT: If this is NOT the registration month of the named registered owner, and you wish to obtain Walking Disability Plates, submit a photocopy of your present registration certificate and a check in the amount of $5.00 (payable to State of N.H. - M.V.) DO NOT MAIL CASH.
MAIL COMPLETED APPLICATION AND ANY REQUIRED FEEDS TO:
ATTN: WALKING DISABILITY DESK
DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES JAMES H. HAYES SAFETY BUILDING 10 HAZEN DRIVE, CONCORD, NH 03305
