Mv2162 Form PDF Details

Are you trying to fill out an Mv2162 Form and have questions? You are not alone. This form can be confusing, so it is important to understand the purpose of the form and what it means for your application or registration process. Knowing how to properly complete this form will put you one step closer to successfully filing your data. In this blog post, we'll give you a comprehensive guide on filling out the Mv2162 Form so that you can become a successful filer!

QuestionAnswer
Form NameMv2162 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmv11, onehalf, dmvdot, wisdot

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WISCONSIN DEPARTMENT OF TRANSPORTATION

Disabled Parking License Plates

Information and Application

MV2162 7/2015 s.341.14(1a) Wis. Stats

Are you eligible?

Any person certified by an authorized health care specialist as having a permanent disability is eligible for the disabled parking license plates. By legal definition, this includes any person who:

Cannot walk 200 feet or more without stopping to rest.

Cannot walk without the use of, or assistance from, another person or brace, cane, crutch, prosthetic device, wheelchair or other assistance devices.

Is restricted by lung disease to the extent that forced 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.

Uses portable oxygen.

Has a cardiac condition to the extent that functional limitations are classified in severity as class III or IV, according to standards accepted by the American Heart Association.

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

Persons that qualify

Disabled parking license plates may be issued to a person with a permanent disability that limits or impairs the ability to walk, who is one of the following:

Owner of a vehicle.

Lessee of a vehicle.

Person who is regularly transported by the owner or lessee of a vehicle.

Employee who is provided a vehicle owned or leased by the employer.

Beneficiary of a trust that owns or leases a vehicle.

Vehicles that qualify

The following vehicles qualify for disabled parking license plates:

An automobile.

A motor home (Annual registration only).

A private truck, dual purpose motor home or dual purpose farm truck that has a gross weight of 8,000 pounds or less.

A farm truck that has a gross weight of 12,000 pounds or less.

A motorcycle (Non-personalized only).

Things you should know

Persons with a permanent disability must be recertified every four years.

Persons with disabled parking license plates may be issued one Disabled Parking Identification (DIS ID) permit.

If you currently have a valid permanent (blue) DIS ID permit, health care certification is not required at this time. If you have two permits, one must be returned with this application.

WisDOT may cancel disabled parking license plates that were issued as a result of fraud or error or that is used by anyone not authorized.

To legally operate your vehicle, you must display license plates within two business days of purchase. If you do not have current plates, apply to a DMV Customer Service Center or an agent authorized by WisDOT to obtain a temporary plate while your disabled parking license plates application is processed. An agent may charge a plate and/or service fee.

Disabled parking license plates must be replaced with regular plates upon the death of the qualifying person. Credit will be given for any remaining months of registration to the surviving spouse.

Permits can be used in any vehicle in which you are a passenger or driver.

Personalized plate information

Personalizing your disabled parking license plates is optional.

A $15 personalized plate fee is required each year in addition to the annual registration fee.

No refund or adjustment will be made for a change of choice or spacing after the plate has been ordered, or if the application is unclear or incorrectly completed.

WisDOT may refuse to issue or may recall after issuance, a request that may be offensive to good taste or decency, misleading or conflicts with any other license plate.

After the Certificate of Registration is issued, allow 4–6 weeks for the manufacturing and mailing process before the plates arrive.

Disabled parking license plates use

A person who displays disabled parking license plates on their vehicle:

May park in spaces marked by official traffic signs reserving the space for vehicles displaying VET or DIS plates or a DIS ID permit.

Is exempt from any parking ordinance imposing time limits of one- half hour or more, and is subject to the laws relating to parking.

May park at a municipally-owned/leased lot without payment in metered spaces when the time limit is one-half hour or more. Payment may be required for privately-owned parking lots or those with an attendant.

May obtain fuel from a full-service pump at the same price as fuel from a self-service pump at locations with both types of services, if the driver is the person with the disability. The driver of the vehicle must ask for the same price as charged for fuel dispensed from a self-service pump. The retailer is not required to provide any other service that is not provided to customers who use a self-service pump.

How to apply

1.Complete the Applicant section

2.Have a health care specialist complete the Health care certification section.

3.If you are requesting a DIS ID permit, you must keep a copy of this completed application and provide it to any traffic officer for inspection upon request. Make and keep a copy before submitting the application to WisDOT.

4.If you want personalized or non-personalized disabled parking license plates, check the appropriate box on the application.

5.If the vehicle you wish to register with disabled parking license plates is already titled in your name, send:

»A copy of your Certificate of Registration or complete the vehicle description on the application.

»The annual registration fee if the current plates expire within the next three months.

»An additional $15 if applying for personalized plates.

6.If the vehicle is not titled in your name, send:

»The title assigned to you.

»A completed title application: MV1 (Private Sale) or MV11 (Dealer Sale).

»All required fees, including annual registration fee.

»An additional $15 if applying for personalized plates.

7.Make check or money order payable to:

Registration Fee Trust.

8.Mail this application and all required items to:

WisDOT

Special Plates Unit – DIS P O Box 7306 Madison, WI 53707-7306

If you have questions about this application:

»Call: (608) 264-7169

»FAX: (608) 267-5106

»E-mail: special-plates.dmv@dot.wi.gov

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Disabled Parking License Plates Information and Application

 

 

 

Wisconsin Department of Transportation

 

MV2162

7/2015

 

s.341.14(1a) Wis. Stats.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant section

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Legal Name of Person with Disability - First, Middle Initial, Last

 

 

 

Female

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

Telephone Number Where You May Be Reached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7 a.m.– 4:30 p.m.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City, State, ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Driver License/Nondriver Identification Number - If none, write NONE

 

 

 

 

I authorize my health care specialist to supply the information requested in this form.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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(Signature of Person with Disability)

 

 

 

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DIS ID permit information

Check if you would also like one Disabled Parking Identification (DIS ID) permit. Please make and keep a copy of this application for your records.

Complete information for the vehicle you wish to register with disabled parking license plates.

 

Current License Plate Number

 

 

Vehicle Year - Make

Body Type

 

Vehicle Identification Number (standard VIN has 17 characters)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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Registration for vehicle owned or leased by: (Please check one)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person with disability.

 

 

 

 

 

 

Person who regularly attends person with disability. Print name and sign below.

 

Employer who provides vehicle to person with disability. Print name and sign

 

Trust whose beneficiary is person with disability. Complete and attach form

 

below.

 

 

 

 

 

 

 

 

 

 

 

MV2790. Sign below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print Name

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Personalized plate section

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please check one

 

I would like non-personalized disabled parking license plates.

 

I would like personalized disabled parking license plates.

Choose 1–6 characters. If you choose six characters, no spaces are allowed. Provide a meaning for your request. i.e. What does this represent?

A

M

B

U

L

8

I M A

B

L

If you choose five or fewer characters, you may request up to two spaces between any two characters. Indicate a space with a diagonal line as shown here. Use capital letters or numbers. The letter O and the number zero are the same. The following are not acceptable: small letters, symbols, signs, hyphens, apostrophes, etc. Carefully distinguish between: letters L or I and number 1, letter S and number 5, letter G and number 6, letter Z and number 2, letter B and number 8, letters U and letter V. For personalized plate message availability, please visit: wisconsindmv.gov/personalizedplatelookup

Meaning of First Choice

1st Choice

Meaning of Second Choice

2nd Choice

Meaning of Third Choice

3rd Choice

Note: If the requested personalized plate choices are not available, non-personalized disabled parking license plates will be issued.

Health care certification

Release of nonexempt information

Under Wisconsin open records law, the Wisconsin Department of Transportation must provide information from its records to requesters.

If you do not want your name and address included in requests we receive for ten or more records, you may ask the department to withhold your name and address from those lists by checking the box below:

Opt Out

ADA – The Wisconsin Department of Transportation complies with the Americans with Disabilities Act.

This section must be completed and signed by any of the following health care specialists licensed to practice in any state: physician, podiatrist, advanced practice nurse, chiropractor, public health nurse or physician assistant who is licensed or certified, or Christian Science Practitioner residing in Wisconsin. An RN must have additional credentials to certify permit eligibility. For faster processing, health care specialists can certify your eligibility online at: https://app.wi.gov/disabledparking

Eligibility Certification Statement – I certify the applicant identified above has a qualifying permanent disability as specified on this form.

X______________________________________________________________

Certification must be based on an exam conducted in the last 12 months.

(Signature of Authorized Health Care Specialist)

(Date)

 

 

 

 

 

Name of Certifying Eligibility (Please Print)

Medical License Number

Area Code and Office Telephone Number

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6 7 8

Address

City

State ZIP Code

If you feel this applicant’s medical condition or disability may prevent them from exercising reasonable control over a motor vehicle, please refer to the WisDOT website at: wisconsindot.gov/Pages/dmv/license-drvs/mdcl-cncrns/medicalmedprofessionals.aspx for the reporting process.

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