Illinois Placard Form PDF Details

Are you an Illinois resident looking for a way to simplify your parking needs? You may qualify for a Placard from the state of Illinois. This helpful document allows individuals with a qualifying disability or condition to easily access designated handicap parking spots wherever they go. In this article, we will provide information about the Illinois Placard form and outline how to apply for one if you meet certain criteria. The application process is made straightforward, so read on if you require more information about this convenient option.

QuestionAnswer
Form NameIllinois Placard Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespersons disabilities placard, illinois placard form, handicap placard renewal form, disabilities plates form

Form Preview Example

State of Illinois Secretary of State 501 S. 2nd Street Springfield, IL 62756

NNEW APPLICANT

NRENEWAL

*If your valid placard was lost/stolen/damaged,

use replacement form VSD 415,

available online at cyberdriveillinois.com or visit your local Secretary of State facility.

Persons with Disabilities Certification for Parking Placard

*This form is valid for three months from your physician’s signature date for a Temporary Placard and six months for a Permanent Placard.

NOTE TO DISABILITY LICENSE PLATE OWNERS: If you have a disability license plate, you MUST complete the form and renew your placard.

DIRECTIONS: Both sides of this document must be signed and completed fully. All fields are required.

Applicants complete Part 1. If the applicant is a MINOR, then Parent/Guardian(s) MUST also complete Part 2. The applicant’s medical profes- sional MUST complete Part 3. If the applicant is applying for meter-exempt parking, his/her medical professional MUST also complete Part 4.

Part 1: Applicant Information (MUST have a valid Illinois driver’s license and/or ID card)

I hereby certify that I meet the definition of a person with a disability as provided in 625 ILCS 5/1-159.1, and I certify that my physical condition entitles me to the issuance of a Persons with Disabilities Parking Placard. By affixing my signature below, I understand that the parking placard may not be used unless I am the driver or passenger of the vehicle.

*If a military veteran, please provide a copy of your DD214 showing proof of service.

 

 

 

 

 

 

 

 

Disability Parking Placard # (if any)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Full Name of Person with Disability (If Minor, complete Part 2 also.)

 

 

 

 

 

Male/Female

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Valid Illinois Driver’s License or ID Card # of Applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Illinois Address

Apt/Unit #

City

 

 

 

 

 

IL

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address if Different from Above

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number

Email Address

 

 

 

 

Military Veteran? Yes / No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Person with Disability

 

 

 

 

 

 

 

Today’s Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part 2: For Parent or Legal Guardian (MUST have a valid Illinois driver’s license and/or ID card)

I hereby certify that the above applicant is a minor and I have primary responsibility for his/her transportation. By affixing my signature below, I understand that the disability placard is issued to the person with disability and may not be used unless I am transporting the disabled person in the vehicle.

Name of Parent or Legal Guardian

 

 

Relationship to Person with Disability

 

 

 

 

 

 

 

Valid Illinois Driver’s License or ID Card #

 

 

 

 

 

 

 

 

 

 

 

 

 

Illinois Address

Apt/Unit #

City

 

 

IL

ZIP

 

 

 

 

 

 

 

Telephone Number

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Parent or Legal Guardian

 

 

 

Today’s Date

 

 

 

 

 

 

 

Warning: Any misuse of the disability parking placard/plates or making a false application may result in the revocation of the placard, a 12- month suspension or revocation of your driver’s license, and a fine of up to $1,000.

Temporary Disabled Parking Placard Applications — May be taken to any Secretary of State facility or mailed in. Permanent Disabled Parking Placard Applications MUST be mailed to the following address:

Secretary of State, Persons with Disabilities Placard Unit, 501 S. 2nd Street, Room 541, Springfield, IL 62756.

*If you have a permanent disability placard and would like a Persons with Disabilities License Plate, please visit your local Secretary of State facility to apply. You will need your permanent placard number and current plate number or VIN.

Please complete Page 2 to ensure timely processing.

Printed by authority of the State of Illinois. July 2021 — 1 — VSD 62.28

Part 3: Medical Eligibility Standards and Medical Professional Certification

As the medical professional(s) executing this document and verifying the nature of the applicant’s disability, I understand that making a false representation of a person’s disability for the purposes of obtaining any type of disabled parking placard may result in suspension or revocation of my license and a fine of up to $1,000. As a licensed physician, advanced practiced nurse, optometrist, chiropractor or physician’s assistant, I certify the applicant has a condition that constitutes him/her as a person with disabilities.

Length of Disability: (Check one)

NTemporary Disability; the duration of this disability is ________________________(maximum 6 months)

NPermanent Disability

NMeter-Exempt Disability (Must complete and sign Part 4 also.)

Check all that apply: (MUST check at least one):

NIs restricted by a lung disease to such a degree that the person’s forced (respiratory) expiratory volume (FEV) for 1 second, when measured by spirometry, is less than 1 liter.

NUses a portable oxygen device.

NHas Class III or Class IV cardiac condition according to the standards set by the American Heart Association.

NCannot walk without the use of or assistance from a wheelchair, a walker, a crutch, a brace, a prosthetic device, or another person.

NIs severely limited in the ability to walk due to an arthritic, neurological, oncological, or orthopedic condition.

NCannot walk 200 feet without stopping to rest because of one of the above five conditions.

Check all that apply: (MUST check at least one diagnosis):

 

 

N Amputation of extremity(s) _________________________

N Arthritis of the ______________________________________

N Spina Bifida

N Osteoarthritis of the

_________________________________

N Multiple Sclerosis

N Chronic Pain due to

_________________________________

N Quadriplegia/Paraplegia

N Legally Blind with limited mobility

NCerebral Palsy

NOther Diagnosis: _________________________________________________________________________________________

If none of the above conditions apply, list the medical condition that impacts the person’s mobility.

Medical Professional’s Printed Name

Specialty

 

 

 

 

Office Address

City, State, ZIP

 

 

 

 

Medical Professional’s Signature

State Professional License Number (NOT NPI#)

Today’s Date

 

 

 

Signature of Collaborating/ Supervising Physician (if signed above by resident/assistant)

Supervising State Professional License Number

 

 

 

 

Part 4: Medical Eligibility for Meter-Exempt Parking

The meter-exempt parking certification must be completed only when the applicant qualifies. To qualify, the applicant MUST have a VALID Illinois driver’s license, have an ambulatory disability described in Part 3, and also have one of the following conditions listed below.

Economic need is not a consideration for meter-exempt parking.

The applicant is eligible for meter-exempt parking as provided by statue due to the following PERMANENT medical condition or disability:

Check all that apply:

NCannot manage, manipulate or insert coins, or obtain tickets in parking meters/ticket machines due to lack of fine motor control of BOTH hands.

NCannot reach above his/her head to a height of 42 inches from the ground due to a lack of finger, hand or upper-extremity strength or mobility.

NCannot approach a parking meter due to his/her use of a wheelchair or other device for mobility.

NCannot walk more than 20 feet due to an orthopedic, neurological, cardiovascular or lung condition in which the degree of debilitation is so severe that it almost completely impedes the ability to walk.

NMissing a hand(s) or arm(s) or has permanently lost the use of a hand or arm.

NPatient is under 18 years of age and incapable of driving.

Medical Professional’s Signature

State Professional License Number (NOT NPI#)

Today’s Date

Signature of Collaborating/ Supervising Physician (if signed above by resident/assistant)

Supervising State Professional License Number

FOR SECRETARY OF STATE OFFICE USE ONLY

Parking Placard Number: ________________________________

Expiration Date: ______________________________________

Issued By: ___________________________________________

Issue Date: __________________________________________

How to Edit Illinois Placard Form Online for Free

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This form requires specific information; to guarantee accuracy, you need to adhere to the next guidelines:

1. The illinois disability parking application usually requires certain information to be typed in. Make sure the following blank fields are filled out:

Tips on how to prepare persons disabilities placard stage 1

2. After filling out this part, head on to the next step and fill out the necessary particulars in all these blank fields - Illinois Address AptUnit City ZIP, Mailing Address if Different from, Telephone Number Email Address, Signature of Person with, Part For Parent or Legal Guardian, Name of Parent or Legal Guardian, Valid Illinois Drivers License or, Illinois Address AptUnit City ZIP, Telephone Number Email Address, and Signature of Parent or Legal.

Filling out segment 2 of persons disabilities placard

3. This third stage is normally easy - complete all the fields in Length of Disability Check one n, measured by spirometry is less, n Uses a portable oxygen device n, If none of the above conditions, Medical Professionals Printed Name, Office Address City State ZIP, and Medical Professionals Signature to finish this segment.

Medical Professionals Printed Name, If none of the above conditions, and measured by spirometry is less of persons disabilities placard

4. To move onward, this next part requires typing in a handful of empty form fields. These comprise of Medical Professionals Signature, Signature of Collaborating, Part Medical Eligibility for, The meterexempt parking, The applicant is eligible for, Check all that apply n Cannot, BOTH hands, or mobility, n Cannot reach above hisher head, n Cannot approach a parking meter, is so severe that it almost, n Missing a hands or arms or has, and Medical Professionals Signature, which you'll find fundamental to moving forward with this particular document.

Step no. 4 in filling out persons disabilities placard

5. To wrap up your document, this particular part requires several additional fields. Filling out Signature of Collaborating, Parking Placard Number Expiration, Issued By Issue Date, and FOR SECRETARY OF STATE OFFICE USE will wrap up the process and you will be done in a flash!

Parking Placard Number  Expiration, FOR SECRETARY OF STATE OFFICE USE, and Issued By  Issue Date inside persons disabilities placard

Always be extremely mindful while completing Parking Placard Number Expiration and FOR SECRETARY OF STATE OFFICE USE, as this is the section in which a lot of people make some mistakes.

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