Form Mvr 32 6 230 – Fill Out and Use This PDF

APPLICANT’S NAME					TELEPHONE NUMBER
					(	)
STREET ADDRESS – PHYSICAL LOCATION				MAILING ADDRESS
CITY	COUNTY	STATE	ZIP	CITY		STATE	ZIP

INDIVIDUALS WITH A LONG-TERM DISABILITY MUST RECEIVE A PHYSICIAN’S CERTIFICATION FOR THE

FIRST FIVE-YEAR PERIOD AND MAY SELF-CERTIFY EVERY OTHER FIVE-YEAR PERIOD THEREAFTER.

Individuals with qualified long-term disabilities must obtain a licensed physician’s certification prior to the initial issuance of disability access placards and/or license plates and at the beginning of every other designated five-year period thereafter. The Commissioner of Revenue, pursuant to Alabama law, authorized beginning January 2002, self-certification of the qualifying disability, under the penalty of perjury. Therefore, individuals with qualified long-term disabilities who renew their disability access placards/license plates after their first designated five-year period may self-certify their qualifying disability and may self-certify every other five-year period thereafter in which they qualify.

Indicate below which privilege is being requested:

DISABILITY ACCESS LICENSE PLATE(S) (to include disability access motorcycle plates) — issued only for vehicles owned by (a) persons with a disability as described below; and (b) organizations that transport persons with a disability as described below.

DISABILITY ACCESS PLACARD(S) — issued only to persons with a disability, as described below, who have a LONG-TERM limitation or impairment in their ability to walk.

TEMPORARY DISABILITY ACCESS PLACARD(S) — issued only to persons with a disability, as described below, who have a TEMPORARY limitation or impairment in their ability to walk (not to exceed six months).

Disability Access license plates and placards may be issued to:

(a)persons with a disability which limits or impairs their ability to walk; or

(b)organizations that transport persons with a disability which limits or impairs their ability to walk (except that organizations SHALL NOT be eligible for placards).

As determined by a licensed physician, persons with disabilities which limit or impair their ability to walk means persons who:

(1) Cannot walk two hundred feet without stopping to rest; or

(2) Cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair, or other assistive device; or

(3) Are 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 60 mm.hg on room air at rest; or

(4) Use portable oxygen; or

(5) Have a cardiac condition to the extent that the person’s functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association; or

(6) Are severely limited in their ability to walk due to an arthritic, neurological, or orthopedic condition.

Physician, check the number(s) above representing the applicant’s specific disability which limits or impairs his/her ability to walk and indicate below the length of disability if temporary.

The undersigned affirms under penalty of perjury that the applicant listed above has the specific disability(ies) as checked above.

		(			)
LICENSED PHYSICIAN’S SIGNATURE						TELEPHONE NUMBER
TYPE OR PRINT NAME				CITY				STATE
DISABILITY ACCESS APPLICANT’S SELF-CERTIFICATION
I certify, under penalty of perjury, that I
continue to meet the requirements for the
disability access license plate/placard as
issued for the previous period.
		APPLICANT’S SIGNATURE (OR LEGAL GUARDIAN)						DATE

See Reverse Side For Organizational Certification, Fees, Quantities, And Other Important Information

Page 1

ORGANIZATIONS ONLY

For Organizational Use. If you are an organization that transports persons with disabilities as described above, check here and DO NOT complete the Physician’s Certification section.

I certify that the vehicle being registered is primarily used to transport persons with disabilities as described above:

ORGANIZATION NAME AND ADDRESS

( )

AUTHORIZED OFFICIAL’S SIGNATURE

TELEPHONE NUMBER

FEES, QUANTITIES AND OTHER IMPORTANT INFORMATION

1.Return this application to your local county tag office to acquire disability access license plates and/or disability access placards.

2.Fees for disability access parking privileges: $23.00 regular fees for each private passenger automobile; $15.00 regular fees for each motorcycle plate; no charge for disability access placards.

Fees (or exemption from fees) for disability access military license plates, such as a disabled veteran disability access plate, shall be the same as the distinctive military license plate.

3.Qualified applicants are entitled to one disability access plate for each motor vehicle they own. They may also obtain one disability access placard regardless of the vehicles owned by the applicant. Those individuals not obtaining a disability access license plate are eligible for one additional placard (for a maximum of two).

4.Applicants who are temporarily qualified may receive one temporary disability access placard.

5.Placards must be displayed in a manner which allows them to be viewed from the front and rear of the vehicle, hung from the front and windshield rearview mirror, and utilized in a parking space reserved for persons with disabilities. When there is no rearview mirror, the placard shall be displayed on the dashboard. Remove the placard from sight when not parked.

6.Disability access license plates, placards, and temporary disability access placards are the only recognized means of identifying vehicles permitted to utilize disability access parking spaces.

7.All states shall recognize disability access license plates, placards, and temporary disability access placards from all other states and countries.

8.A separate physician’s certification is not required to obtain additional disability access license plates, placards, or temporary disability access placards.

COMPLETE THE SECTION BELOW FOR

REPLACEMENT OF LOST, STOLEN, OR MUTILATED DISABILITY ACCESS PLATES OR PLACARDS

APPLICANT’S NAME					TELEPHONE NUMBER
					(	)
STREET ADDRESS – PHYSICAL LOCATION				MAILING ADDRESS
CITY	COUNTY	STATE	ZIP	CITY		STATE	ZIP

PRIVILEGE TO BE REPLACED AFFIDAVIT

Indicate below which privilege is being replaced:

DISABILITY ACCESS LICENSE PLATE(S) (to include disability access motorcycle plates) — issued only for vehicles owned by (a) persons with a disability as described on page one; and (b) organizations that transport persons with a disability, as described on page one.

DISABILITY ACCESS PLACARD(S) — issued only to persons with a disability, as described on page one, who have a LONG- TERM limitation or impairment in their ability to walk.

TEMPORARY DISABILITY ACCESS PLACARD(S) — issued only to persons with a disability, as described on page one, who have a TEMPORARY limitation or impairment in their ability to walk (not to exceed six months).

I certify, under penalty of perjury, that the disability access privilege indicated above is being replaced for the reason checked below:

Lost	Stolen	Mutilated
		APPLICANT’S SIGNATURE (OR LEGAL GUARDIAN)		DATE

Page 2