Georgia Mv 9D Form PDF Details

This is an article about the Georgia Mv 9D form, which is a document that businesses in the state of Georgia use to report various types of taxable transactions. The information on this form can be used by the government to determine how much money it needs to collect in taxes, and businesses in Georgia are required to complete and submit this form every quarter. In addition, there are also specific instructions for completing this form that must be followed closely in order to ensure that the information is accurate and up-to-date.

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QuestionAnswer
Form NameGeorgia Mv 9D Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshow to ga disabled parking, disability dmv form parking, georgia disabled, georgia disabled parking permit

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MV-9D (Revised 1-2019)

Web and MV Manual

Georgia Department of Revenue - Motor Vehicle Division

Person with Disability Parking Placard/License Plate Application

Purpose of this form: This form is to be used to request a Person with Disability Parking Placard or a Disabled Person’s License Plate. This form should not be used to record a change of ownership, change of address, or change of license plate classification.

How to submit this form: After reviewing the MV-9D form instructions, this fully completed form must be submitted to your local County tag office. Please refer to our website at https://dor.georgia.gov to locate the address(es) for your specific county.

 

A

 

 

REQUEST TYPE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check applicable box(es) below:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Placard No.: Record placard number if

 

[

]

Disabled Person’s Parking Permit (Placard):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

renewing or replacing placard.

 

 

 

 

[

] New Issuance: [

] Temporary Placard [ ] Permanent Placard [ ]

Special Permanent Placard

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[

] Renewal (Permanent Placards Only) Record placard number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[

] Replacement: [ ]

Lost [ ] Stolen Record previous placard number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[

]

Disabled Person’s License Plate Fee: $20.00 Plate Fee plus any taxes that maybe due. Please Note: Section D must be completed and notarized.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B

 

 

APPLICANT INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disabled Person’s

 

First Name

Middle Initial

Last Name

Suffix

Telephone No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Legal Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Address:

 

Street No.

Street Name

Apt./Suite No.

City

 

 

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver’s License No.:

 

 

 

 

State of Issuance:

 

 

County:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

 

 

PARENT/GUARDIAN INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note: If you are the parent or adult charged by law with the natural parent’s rights, duties and responsibilities acting on behalf of a minor child (under 18) in place of the child’s natural parents (person in loco-parentis), you must complete the information below.

Parent/Guardian’s

 

 

First Name

 

Middle Initial Last Name

 

Suffix

 

Relationship

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Legal Name:

 

 

 

 

 

 

 

 

 

to Applicant:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Address:

 

 

Street No.

Street Name

Apt./Suite No.

City

 

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver’s License No.:

 

 

 

 

State of Issuance:

 

County:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D CERTIFICATION FROM A LICENSED OR CERTIFIED HEALTH CARE PROVIDER

I hereby certify that the person with the disability listed above is under my care and has the following condition listed on the reverse side of this application under

 

“Eligibility Requirements.” Enter Reason Code No.:

 

 

 

(Note: Only those conditions listed on the reverse side of this application qualify

 

 

an applicant for a Person with Disability Parking

 

Placard.) **PLEASE SEE INSTRUCTIONS BEFORECOMPLETING**

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Care Provider’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sworn to and subscribed before me

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical License No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

this ____ day of _______________, ______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Day

 

Month

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notary Seal or Stamp

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical Address:

 

Street No., Street Name, Suite No.

 

City, State, ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

____________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notary Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

 

____________________________

 

 

 

 

Telephone No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Commission Expiration Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E

 

 

INSTITUTION/BUSINESS INFORMATION (This vehicle is used primarily for transportation of disabled persons.)

 

 

 

 

 

 

 

 

Institution/Business

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FEIN:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Legal Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vehicle Identification No.:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Make:

 

 

Model:

 

 

 

 

 

 

Tag No.:

 

 

 

 

 

 

 

 

 

Year:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorized Representative’s

 

 

 

 

 

 

 

 

 

 

 

Position/ Job Title:

 

 

 

 

 

 

 

 

Printed Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Authorized Representative’s

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

/

 

 

/

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F APPLICANT SIGNATURE

I state that I have read and signed this application after its completion, and I swear or affirm that the statements made herein are true and correct, and I acknowledge that any person knowingly or willfully making a false statement on or pursuant to this application is guilty of a misdemeanor under Georgia Code §40-2-74(a.1).

 

 

 

 

 

 

Signature:

 

Date:

/

/

 

 

 

 

 

 

 

Have a question? Visit our website at https://dor.georgia.gov/motor-vehicles or scan the QR code above for more information.

INSTRUCTIONS

How to complete the MV-9D Form

COMPLETING THIS FORM

Temporary Placard: Complete Sections A, B, C, D and F. Note: Only licensed health care providers may certify disabilities for temporary placards. Temporary placards may not be extended for an additional period of time. When additional time is needed, a new application must be completed and certified by a health care provider. In addition, please list your previous placard number. Temporary placards are only issued for a period of time not to exceed six months.

Permanent Placard: Complete Sections A, B, C, D and F. Note: Individuals should list their Georgia Driver’s License number or Photo ID number in the space provided. Businesses should list their Business ID number (Bus. ID) where indicated (i.e., E.I.N.) and provide a copy of business license.

Special Permanent Placard: Follow the instructions for a Permanent Placard. A Special Permanent Placard (gold placard) is issued only to an individual with a disability who (1) drives a motor vehicle equipped with hand controls for the operation of brakes and accelerator or (2) is disabled due to loss, or loss of use, of both upper extremities.

Renewal Request: Complete Sections A, B and F. Note: Notarization is not required.

Replacement Request: Indicate if applying for a replacement placard. Please check reason for replacement (Lost or Stolen). List your previous placard number and complete Sections A, B and F.

Institution/Business Information: Complete Sections A, B, E and F. Follow these additional special instructions:

Institutions, as defined by Georgia Code §31-7-1, must attach a copy of the institutional license. Note: To qualify for a permit, the institution must operate the vehicle primarily to transport individuals with disabilities.

Businesses, to qualify for a special plate, must meet the requirements of Georgia Code §40-2-74, including limits on the type of business organization. Note: The business vehicle must be used only or primarily by the disabled employee for whom the plate was issued.

Please Note:

A placard is to be used only when the vehicle in which it is displayed is parked and is being used for the transportation of the person with disability or the severely disabled veteran.

Any vehicle lawfully displaying a placard will qualify for parking in areas designated for use by persons with disability only.

The placard will not allow vehicles to park where parking is prohibited.

The placard is required to be displayed when the vehicle is parked in areas designated for use by persons with disability only and must not be displayed when the vehicle is being operated on the highway.

Each eligible individual will be issued only one placard.

ELIGIBILITY REQUIREMENTS – REASON CODES

1.

Applicant is so ambulatory disabled that he/she cannot walk 200 feet

5.

Applicant has a cardiac condition to the extent that his/her functional

 

without stopping to rest.

 

limitations are classified in severity as Class III or Class IV according to

2.

Applicant cannot walk without the use of assistance from a brace, a cane, a

 

standards set by the American Heart Association.

 

crutch, another person, a prosthetic device, a wheelchair, or other assistive

6.

Applicant is severely limited in his/her ability to walk due to an arthritic,

 

device.

 

 

neurological, orthopedic condition or complications due to pregnancy.

3.

Applicant is restricted by lung disease to such an extent that his/her forced

 

7.

Applicant is hearing impaired person pursuant to Georgia Code §24-6-651.

 

respiratory volume for one second, when measured by spironmetry is less

 

than one liter, or when at rest his/her arterial oxygen tension is less than 60

8.

Applicant is a blind individual whose central visual acuity does not exceed

 

millimeters of mercury on room air.

 

20/200 in the better eye with correcting lenses or whose visual acuity, if

4.

Applicant uses portable oxygen.

 

better than 20/200, is accompanied by a limit to the field of vision in the

 

 

 

better eye to such a degree that its widest diameter subtends an angle of

no greater than 20 degrees.

QUALIFYING VEHICLES

A passenger vehicle or truck with a registered gross weight of not more than 10,000 lbs. This restriction does not apply to institution or business applications.

CERTIFICATION FROM A LICENSED OR CERTIFIED HEALTH CARE PROVIDER

“For purposes of this Code section (40-2-74.1) the department shall accept, in lieu of an affidavit, a signed and dated statement from the doctor which includes the same information as required in an affidavit written upon security paper as defined in paragraph (38.5) of Code Section 26-4-5."

Please Note: Certification in lieu of an affidavit (completion and notarization of Section D) can only be submitted for placards and cannot be provided on license plate applications.

Who may provide certification: Health care providers that are permitted to provide a certification are limited to medical practitioners licensed to practice under Article 2 of Chapter 34 of Title 43 (physicians); Chapter 35 of Title 43 (podiatrists); and Chapter 9 of Title 43 (chiropractors) of the Georgia Code.

Jane Doe

40

123 Main St.

 

Secured paper document (as defined by GA Code 26-4-5) from healthcare provider must include:

• Specific disability as indicated on MV-9D instructions form.

• Indication of permanent or temporary disability

• Stamp or signature of healthcare provider

• Date

SAMPLE

SUBMITTING THIS FORM

After reviewing the MV-9D form instructions, this fully completed form must be submitted to your local County tag office. Please refer to our website at https://dor.georgia.gov to locate the address(es) for your specific county.

Have a question? Visit our website at https://dor.georgia.gov/motor-vehicles or scan the QR code above for more information.

Watch Georgia Mv 9D Form Video Instruction

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