Form Mv 145A PDF Details

Navigating the complexities of parking privileges for individuals with disabilities in Pennsylvania involves understanding the role and requirements encapsulated in the MV-145A form. This critical document serves as an application for a Person with Disability Parking Placard, sanctioned by the Pennsylvania Department of Motor Vehicles (PennDOT), and is central to acquiring the necessary placard to access designated parking spaces. The form distinguishes between several types of requests, including original submissions, renewals for permanent placards, replacements due to loss or damage, and changes in personal information like address or name. It is meticulously designed to ensure that individuals with disabilities, as well as severely disabled veterans, can obtain parking placards, either on a permanent or temporary basis, contingent on the certification by a licensed health care provider or, for veterans, verification of a service-connected disability. These placards afford individuals the ability to park in spaces specifically reserved for those with disabilities, underscoring the importance of accuracy and truthfulness in completing the application. It's also noteworthy that the form specifically caters to organizations that transport persons with disabilities, outlining the criteria and documentation required for these entities to receive a placard. With no fee required but strict eligibility requirements and warnings against misuse or fraudulent applications, the MV-145A form plays a pivotal role in ensuring that parking accommodations are accessible to those with legitimate needs, fundamentally supporting their mobility and independence within the community.

QuestionAnswer
Form NameForm Mv 145A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespa handicap placard, pennsylvania handicap placard, renew handicap placard pa, pa handicap placard application

Form Preview Example

MV-145A (7-21)

www.dmv.pa.gov

PERSON WITH DISABILITY PARKING PLACARD APPLICATION NO FEE REQUIRED

SEE REVERSE SIDE FOR INSTRUCTIONS AND ELIGIBILITY REQUIREMENTS

FOR DEPARTMENT USE ONLY

Bureau of Motor Vehicles • P.O. Box 68268 • Harrisburg, PA 17106-8268

q ORIGINAL REQUEST - qPermanent Placard

CHECK ( 4) APPROPRIATE BLOCKS BELOW

qSeverely Disabled Veteran qTemporary Placard

q RENEWAL REQUEST - (For Permanent Placards Only)

q REPLACEMENT REQUEST - qPLACARD

qID CARD qDefaced qLost q Stolen q Never Received PREVIOUS PLACARD # __________________

q CHANGE OF ADDRESS - Complete Sections A and E. NOTE: Notarization is not required.

qCHANGE OF NAME - Complete Sections A and E. Check here to indicate reason for change of name: qMarriage qDivorce qOther: ______________________

APERSON WITH DISABILITY INFORMATION - LIST NAME AND ADDRESS OF PERSON WITH DISABILITY - NOTE: If listing an out-of-state address, you must also complete and attach Form MV-8.

 

Last Name (or Full Business Name)

First Name

 

 

Middle Name

PA DL/Photo ID#

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

or Bus. ID#

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Email Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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. In addition, a parent, including an adoptive or foster parent who has custody care or control of the child or adult child or a spouse may sign on

 

behalf of the child, adult child or spouse (applicant) provided the applicant meets eligibility requirements (1) through (8).

 

 

 

 

 

 

 

 

 

 

 

Name of Parent, Person in Loco Parentis or Spouse

 

 

 

 

 

 

Relationship to Applicant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CERTIFICATION FROM A HEALTH CARE PROVIDER LICENSED OR CERTIFIED IN PA OR A CONTIGUOUS STATE (NEW YORK, NEW JERSEY, DELAWARE, MARYLAND, WEST VIRGINIA OR

B

OHIO). THIS SECTION MUST BE COMPLETED IN FULL. HEALTH CARE PROVIDERS MAY ONLY CERTIFY DISABILITIES WITHIN THEIR SCOPE OF PRACTICE. WARNING: Altering or forging a

document issued by the Department, such as a disabled person parking placard, or possessing, using or displaying such a document knowing it to have been altered, forged or counterfeited,

 

is a misdemeanor of the first degree pursuant to the Vehicle Code, 75 Pa.C.S. Section 7122, punishable by a fine of not more than $10,000 or imprisonment of not more than five years, or both.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

UNCORRECTED

 

application under “Eligibility Requirements”: _______________

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

R

20/

 

 

 

 

 

 

List Reason Code # Here

 

an applicant for a person with disability placard.)

 

 

L

20/

 

 

 

 

 

NOTE: If reason code #1 is listed above, please indicate the individual's visual acuity by completing the chart to the right:

 

 

B

20/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If reason code #4 is listed above, please indicate the type of device used: ________________________________________________

 

 

CORRECTED

 

 

R

20/

 

 

 

 

 

Temporary placards are only issued for a period of time not to exceed six months. If the applicant requires additional time after the expiration of

 

 

 

 

 

L

20/

 

 

 

 

 

the placard issued, the applicant must be recertified by a health care provider.

 

 

 

 

B

20/

 

 

 

 

 

Health Care Provider’s Printed Name

 

 

Health Care Provider’s Signature

 

 

 

 

 

Medical License No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Street Address

 

 

 

City

 

State

Zip Code

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C

CERTIFICATION BY POLICE OFFICER - Police officer may only certify that the applicant does not have full use of a leg or both legs, or is blind.

 

NOTE: If Section B above is completed, please skip this Section and go on to Section E.

 

 

 

 

 

 

 

 

 

This is to certify that the person with disability listed above has the condition listed and is entitled to the use and privileges of the person with disability

 

parking placard.

qis blind, OR does not have full use of a leg or both legs as evidenced by the use of a: qwheelchair

qwalker

 

qcrutches

q cane/quad cane

 

 

q other prescribed device

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Officer’s Printed Name

 

 

 

 

Officer’s Signature

 

 

 

 

 

Badge Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Office Street Address

 

 

 

City

 

State

Zip Code

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

CERTIFICATION FROM U.S. DEPARTMENT OF VETERANS AFFAIRS REGIONAL OFFICE ADMINISTRATOR (PHILADELPHIA OR PITTSBURGH)

DOR SERVICE UNIT IN WHICH THE VETERAN SERVED OR A LEGIBLE PHOTOCOPY OF THE APPLICANT'S LETTER OF PROMULGATION, AWARDS LETTER, SINGLE NOTIFICATION, OR SUMMARY OF BENEFITS LETTER.

qThis is to certify that the veteran listed above with VA number ___________________________, has a 100% service-connected disability or has the following service connected disability reason code number _______, listed on the reverse side of this application under “Eligibility Requirements.” NOTE: If reason code #4 is listed, please indicate the type of device used: __________________________.

Authorized Printed Name and Title: ____________________________________________ Authorized Signature: ____________________________________________

qIn lieu of the U.S. Department of Veterans Affairs Regional Office Administrator certification, I have attached a legible photocopy of my Letter of Promulgation, Awards Letter, Single Notification Letter, or Summary of Benefits Letter that indicates I have a 100% service-connected disability.

E NOTARIZATION AND APPLICANT SIGNATURE - Person with disability, natural parent or other authorized person listed in Section A must sign below.

SUBSCRIBED AND SWORN

 

 

 

I state that I have read and signed this application after its completion, and I swear or

TO BEFORE ME:

MONTH

DAY

YEAR

 

affirm that the statements made herein are true and correct, and that any statement

 

 

 

 

 

 

made on or pursuant to this application is subject to the penalties of 18 Pa.C.S.

 

 

 

 

 

 

 

 

SIGNATURE OF PERSON ADMINISTERING OATH

 

 

Section 4903 (a)(2) (relating to false swearing), which shall include punishment of a

 

 

 

 

fine not exceeding $5,000, or to a term or imprisonment of not more than two years,

S

 

 

 

 

 

or both.

 

 

 

 

 

 

T

 

SIGN IN PRESENCE OF NOTARY

 

 

 

 

(

)

 

A

 

 

 

 

Person with Disability Signature

 

Date

 

 

Telephone Number

 

M

 

 

 

 

 

 

THIS APPLICATION MAY BE DUPLICATED

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INSTRUCTIONS

1.Permanent Placard - Complete Sections A, B or C (NOT BOTH) and E. NOTE: Individuals should list their PA Driver’s License (PA DL) or Photo ID# in the space provided. Businesses should list their Business ID# (Bus. ID) where indicated (i.e. E.I.N.).

2.Severely Disabled Veteran Placard - Complete Sections A, D and E.

3.Temporary Placard - Complete Sections A, B and E. NOTE: Only licensed health care providers* may certify disabilities for temporary placards. Temporary placards may be issued for a period up to six months and 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.

4.Renewal Request - Complete Sections A and E. NOTE: Notarization is not required.

5.Replacement Request - Indicate if applying for a replacement placard or ID card. Please check reason for replacement; Lost, Stolen, Defaced or Never Received. List your previous placard number and complete Sections A and E. NOTE: If product was not received within 90 days, please check the "Never Received" box or if product was not received for over 90 days please check the "Lost" box.

6.Change of Address - Complete Sections A and E. NOTE: Notarization is not required.

7.Change of Name - Complete Sections A and E. Check the block on the front of this application to indicate reason for change of name. NOTE:

Notarization is not required.

*Health Care Provider is defined as a physician, chiropractor, optometrist, podiatrist, physician assistant, or a certified registered nurse practitioner licensed or certified in Pennsylvania or a contiguous state. Health care providers may only certify disabilities within their scope of practice.

Placard Type

Eligibility Requirements

Qualifying Vehicles

Benefits

Person with Disability Placard

“Reason Codes”

Applicant:

(1)is blind.

(2)does not have full use of an arm or both arms.

(3)cannot walk 200 feet without stopping to rest.

(4)cannot walk without the use of, or assistance from, a brace, cane, crutch, another person, prosthetic device, wheelchair or other assistive device.

(5)is 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.

(6)uses portable oxygen.

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

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

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), complete the appropriate information on the front side of this application.

In addition, a parent, including an adoptive or foster parent who has custody, care, or control of the child or adult child or a spouse, may sign on behalf of the child, adult child, or spouse (applicant) provided the person with disability meets eligibility requirements (1) through (8).

(1)A passenger vehicle or truck with a registered gross weight of not more than 14,000 lbs.

(2)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.

NOTE: Organizations that operate a passenger vehicle to transport persons with disabilities must supply the Department with the following:

a)A notarized statement of how the placard will be used and the type of services that will be provided.

b)The weekly or monthly number of hours that the services are provided.

c)The make of the vehicle(s), including the title number, vehicle identification number and registration plate number. The vehicle(s) must be titled in the name of the organization and must be a passenger vehicle.

d)The number of placards required: (Organizations may not be issued more than eight placards in the organization’s name.)

(1)Parking permitted in spaces designated for disabled persons and for 60 minutes in excess of legal parking period except where local ordinances or police regulations provide for the accommodation

of heavy traffic during morning, afternoon or evening hours.

(2)Upon request of a person with disability, local authorities may erect on the highway as close as possible to the person’s residence a sign(s) indicating that the place is reserved for the person with disability, that no one else may park there unless a person with disability plate or placard is displayed and that any unauthorized person parking there will be subject to a fine.

Severely

Disabled

Veteran

Placard

(1)100% service-connected disability certified by the U.S. Department of Veterans Affairs (Pittsburgh or Philadelphia) or service unit in which the veteran served or as shown on the applicant’s Letter of Promulgation, Awards Letter, Single Notification Letter, or Summary of Benefits Letter.

(2)Same disabilities as listed above for Person with Disability Placard but must be service-

Same as 1 and 2 above for Person with Disability Placard.

Same as above for Person with Disability Placard.

Use of Person with Disability and Severely Disabled Veteran Placards:

. Parking in a designated persons with disability parking space is only permitted with this parking placard when the vehicle is being used for the transportation of the person for which the parking placard was issued.

. Any vehicle lawfully displaying a parking placard will qualify for parking in areas designated only for use by persons with a disability. NOTE: This parking placard can not be used to park where parking is prohibited.

Send completed application to: PennDOT, Bureau of Motor Vehicles, P.O. Box 68268, Harrisburg, PA 17106-8268

Visit us at www.dmv.pa.gov or call us at 717-412-5300. TTY callers — please dial 711 to reach us.

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Make sure you provide your details in the box Office Street Address, City, State, Zip Code, Telephone Number, C CERTIFICATION BY POLICE OFFICER, NOTE If Section B above is, This is to certify that the person, is blind OR does not have full use, other prescribed device, canequad cane, Officers Signature, Badge Number, wheelchair, and crutches.

penndot handicap placard Office Street Address, City, State, Zip Code, Telephone Number, C CERTIFICATION BY POLICE OFFICER, NOTE If Section B above is, This is to certify that the person, is blind OR does not have full use, other prescribed device, canequad cane, Officers Signature, Badge Number, wheelchair, and crutches fields to fill out

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