Form Td 420 073 – Fill Out and Use This PDF

Disabled Parking Application

For Individuals

(See page two for instructions)

A parking permit for a person with disabilities may be issued only for a medical necessity that severely affects mobility or involves acute sensitivity to light (RCW 46.16.381). Knowingly providing false information on this application is a gross misdemeanor. The penalty is up to one year in jail and a fine of up to $5,000 or both. Unauthorized use of the placard or license plate is a traffic infraction with a monetary penalty.

Applicant

Please PRINT or TYPE name of applicant (Last, First, Middle initial)		Date of birth		Sex
				Male	Female
Mailing address and apartment number (if applicable)		Current license plate number (if applicable)
City, state, ZIP code	(Area code) daytime telephone number		Registration expiration (if applicable)
One parking placard, no fee	One parking placard and one set of license plates; a fee
Two parking placards, no fee	will be charged for the plates *
One disabled parking tab; a fee will be charged *	One set of license plates; a fee will be charged *
One parking placard and one disabled parking tab;

a fee will be charged for the tab *

*The applicant must be a registered owner of the vehicle which the plates or tab will be assigned to.

I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

____________________________________	X
Date and place	Applicant signature

Physician – complete all areas below

City, state, ZIP code

Cannot walk two hundred feet without stopping to rest

Is severely limited in ability to walk due to arthritic, neurological, or orthopedic condition Cannot walk without the use of an assistive device

Uses portable oxygen

Ability to walk is restricted by lung disease to such an extent that forced expiratory respiratory volume, when measured by spirometry, is less than one liter per second, or the arterial oxygen tension is less than sixty mm/hg on room air at rest

Class III impairment by cardiovascular disease (see instructions) Class IV impairment by cardiovascular disease (see instructions)

Has a disability resulting from acute sensitivity to automobile emissions, which limits or impairs the ability to walk and the severity of this disability is comparable to the other conditions listed above

Is restricted by a form of porphyria to the extent that the applicant would significantly benefit from a decrease in exposure to light

Legally blind with limited mobility

I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct.

____________________________________	X
Date and place	MD, DO, DC, DPM, ND, ARNP, or PA signature (stamped signatures not allowed)

TD-420-073 (R/9/09)W Page 1 of 2

Instructions

Applicant

1.Enter your personal information in the space provided.

2.If your disabled parking privilege is permanent, check one of the boxes to select the display type. If your privilege is temporary you don’t need to check a box; you will receive a temporary placard.

3.Complete and sign only the applicant section. For the purposes of this application, “signature” means any memorandum, mark, or sign made with the intent to authenticate an application. If you sign using your mark, the signatures of two witnesses are required. The following parties may sign on your behalf:

฀•฀ A฀family฀member,฀stating฀their฀relationship฀to฀you.฀For฀example:฀Signature,฀Jane฀Doe,฀daughter.

฀•฀ Someone฀with฀a฀Power฀of฀Attorney.฀Attach฀a฀copy฀of฀the฀notarized Power of Attorney.

฀•฀ A฀legal฀guardian.฀Attach฀a฀copy฀of฀the฀Guardianship฀papers.

4.Have your physician complete all areas of the physician section.

5.Once completed by your physician, return it to any qualifying vehicle licensing office (see our website for restrictions). If you are applying for permanent priveleges, you must return the original application. If you are applying for temporary privileges, we will also accept a direct fax from your physician’s office.

Physician

1.Complete all areas of the physician section.

2.For a temporary privilege, check the Temporary box and indicate the number of months. For a permanent privilege, check the Permanent box.

3.Check the appropriate condition(s) that apply.

4.Sign and return the application to the applicant (we cannot accept stamped signatures). The following professionals are authorized to sign: Physician & Surgeon - MD or DO, Chiropractor - DC, Podiatrist - DPM,

Naturopath - ND, Advanced Registered Nurse Practitioner - ARNP, Physician’s Assistant - PA. WAC 308-96B-010

Class III impairment by cardiovascular disease - Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain.

Class IV impairment by cardiovascular disease - Patients with cardiac disease resulting in an inability to carry on any physical activity without discomfort. Symptoms of heart failure or of the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.

Placard display

If you park in disabled parking, you must display the placard by hanging it on the rearview mirror or, if there is no mirror post, placing it on the dashboard. Before leaving the parking stall, remove the placard from the rearview mirror.

License plates or disabled parking tab (for qualifying plates)

Enclose a copy of your current registration. To qualify, you must be a registered owner of the vehicle that the plates will be assigned to. If you sell your vehicle, the plates must be transferred to another vehicle owned by you or surrendered to a vehicle licensing office.

Replacement

You may request a replacement placard, plate, or disabled parking tab at most vehicle licensing offices.

Renewing parking privileges

Permanent privileges must be renewed every 5 years. You will receive a renewal notice before your expiration. Temporary placards are not renewable. If the disability persists, a new completed application is required.

Return requirements

The placard(s), plates, and identification card must be returned to us when the individual issued these privileges passes away.

Services and parking restrictions

•You may park, free of charge, for time periods specified on posted signs in regular street-parking spaces or at parking meters. A local jurisdiction providing nonmetered, on-street parking places reserved for persons with physical disabilities may impose, by ordinance, time restrictions of no less than four hours on the use of these parking places. Parking is not permitted in areas where stopping, parking, or standing of all vehicles is prohibited or reserved for special types of vehicles (fire lanes, loading zones, bus lanes, etc.).

•You may request refueling service at gasoline stations for the self-service price if a passenger is not capable of fueling the vehicle for you. Stations exclusively self-service and convenience stores with remotely controlled gas pumps are exempt. No other station services are covered.

Identification (ID) cards

We will mail your ID card to you 2 to 4 weeks after we have processed your application. Keep it in your wallet or purse. You must provide it to law enforcement when asked.

For more information

Visit www.dol.wa.gov, call a vehicle licensing office listed in the yellow pages or (360) 902-3770, or write to:

Individual with Disabilities, Department of Licensing, PO Box 9043, Olympia, WA, 98507-9043.