Mv145A Form – Fill Out and Use

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

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.