Form Dsmv 16 PDF Details

Form Dsmv 16 is an important document for residents of the state of Delaware. It allows you to update your information on file with the DMV, including your name, address, and vehicle information. Completing this form is essential if you have recently moved or changed your name. Failing to submit the updated information can lead to fines and other penalties. Make sure to fill out and submit Form Dsmv 16 as soon as possible to avoid any issues.

You'll find more information about the form dsmv 16 by looking through the table we put together for you.

QuestionAnswer
Form NameForm Dsmv 16
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnh handicap placard application, handicap placard, nh handicap placard form, new hampshire handicap placard application

Form Preview Example

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

 

 

 

 

 

 

 

 

 

APPLICANTS

STREET ADDRESS OR RFD AND BOX NO.

 

TELEPHONE # (OPTIONAL)

 

 

 

 

 

 

 

 

 

MUST

 

 

 

 

 

 

 

 

 

COMPLETE

CITY OR TOWN

COUNTY

 

STATE

 

ZIP CODE

THIS

 

*

 

 

 

 

 

 

 

SECTION

MONTH

DAY YEAR

V

PLATE NO.

 

PLATE TYPE

MFG. YR.

MODEL

 

 

 

E

 

 

 

 

 

 

 

DOB:

 

H

 

 

 

 

 

 

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

 

 

(Not to exceed six months)

Brief Description of walking disability: ___________________________________________________________________________

PHYSICIAN’S SIGNATURE

M.D. DATE

PHYSICIAN’S NAME (PRINT LEGIBLY)

 

ADDRESS

 

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:

►

Signature of ApplicantTelephone#

BUSINESS OWNER

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

MONTH DAY YEAR

V E H

PLATE NO.

PLATE TYPE MFG. YR.

MAKE MODEL

WALKING DISABILITY PLATES

WALKING DISABILITY VANITY PLATES WALKING DISABILITY PLACARD NO.

ISSUED:

DSMV16 (Rev.02/00)

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

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entering details in walking disability nh 2018 form step 1

Type in the appropriate details in the area The condition is, PERMANENT TEMPORARY, for a period of Months, Not to exceed six months, Brief Description of walking, PHYSICIANS SIGNATURE PHYSICIANS, MD DATE, lWe certify under penalty of, Business Name, ORGANIZATIONS COMPLETE THIS, Signature of ApplicantTelephone, BUSINESS OWNER, VEHICLE OWNER PRINT FULL ADDRESS, LAST NAME, and FIRST NAME.

stage 2 to completing walking disability nh 2018 form

The application will require information to effortlessly fill up the field VEHICLE OWNERS DATE OF BIRTH, MONTH DAY YEAR, V E H, PLATE NO, PLATE TYPE, MFG YR, MAKE, MODEL, WALKING DISABILITY PLATES, WALKING DISABILITY VANITY PLATES, ISSUED, and DSMV Rev.

walking disability nh 2018 form VEHICLE OWNERS DATE OF BIRTH, MONTH DAY YEAR, V E H, PLATE NO, PLATE TYPE, MFG YR, MAKE, MODEL, WALKING DISABILITY PLATES, WALKING DISABILITY VANITY PLATES, ISSUED, and DSMV Rev blanks to complete

Step 3: If you are done, hit the "Done" button to upload the PDF document.

Step 4: Produce a duplicate of each separate document. It will save you time and permit you to remain away from complications later on. Keep in mind, your details isn't going to be revealed or checked by us.

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