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MV-9D (Rev. 05-2006) Disabled Person’s Parking Affidavit www.dor.ga.gov Section One – Except for signature(s), this form must be typed, electronically completed and printed or legibly hand printed. Note: The vehicle owner information is only required when applying for a DP license plate. You do not have to own a vehicle to obtain a DP parking permit (placard). *Vehicle Owner’s Full Legal Name *Driver’s License # & Name of Issuing State *Vehicle Owner’s Street Address including city, state & zip *County of Residence Disabled Person’s Full Legal Name *Relationship to Vehicle Owner – Check only one box □ Child □ Self □ Spouse □ Ward Disabled Person’s Street Address including city, state & zip Section Two For Institutions Only: This vehicle is used primarily for the transportation of disabled persons. Institution’s Full Legal Name (Institution as defined by Georgia Law §31-7-1) - Attach a copy of institutional license Vehicle Year & Make Vehicle Identification # Vehicle Color Vehicle Tag # Institution Authorized Representative’s Signature & Position – ‘PARKING PERMITS (Placards) ONLY’ Date Section Three Check applicable box(s) below: You may apply for both a Disabled Person’s Parking Permit and a Disabled Person’s License Plate with this form. □ Temporary Parking Permit (Placard) No Fee – Not valid for more than six months. □ Permanent Parking Permit (Placard) No Fee – Must be replaced every four years from issue date. □ Special Permanent Parking Permit (Placard) No Fee – Because of a physical disability, drives a motor vehicle which has been equipped with hand controls for the operation of the vehicle’s brakes and accelerator; or is physically disabled due to the loss of, or loss of use of, both upper extremities. Must be replaced every four years from issue date. □ Disabled Person’s License Plate (Fee $20.00 plus any taxes that may be due). Section Four – To be completed by the practitioner of the healing arts as defined in Georgia Law §40-6-221(5.1), as amended. Is disability permanent? Yes No I hereby swear and affirm that the above individual as defined by Georgia Law §24-9-101 and §40-6-221(5): □ Is hearing impaired pursuant to Georgia Law §24-9-101. □ Is so ambulatorily disabled that he/she cannot walk 200 feet without stopping to rest. □ Cannot walk without the use of or assistance from a brace, a cane, a crutch, another person, a prosthetic device, a wheelchair, or other assistive device. □ Is restricted by lung disease to such an extent that his/her forced 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 millimeters of mercury on room air. □ Uses portable oxygen. □ Has a cardiac condition to the extent that his/her functional limitations are classified in severity as Class III or Class IV according to standards set by the American Heart Association. □ Is a blind individual whose central visual acuity does not exceed 20/200 in the better eye with correcting lenses or whose visual acuity, if better than 20/200, is accompanied by a limit to the field or vision in the better eye to such degree that is widest diameter subtends an angle of no greater than twenty-degrees (20). □ Is severely limited in his/her ability to walk due to an arthritic, neurological, or orthopedic condition or complications due to pregnancy. Section Five – Certification Practitioner of the Healing Arts’ Printed Name GA License # Signature Date Office Street Address including city, state & zip Telephone# including area code ( ) Note: Notarization Required For Practitioner of the Healing Arts’ Signature Notary Public’s Signature & Notary Seal or Stamp Sworn to and subscribed before me This of (Day) (Month) (Year) Date My Notary Commission Expires County and State Use Only Inventory# Issue Date Replacement Permit? Yes* □ No □ * If yes, Replacement Permit New Application? □ Yes □ No *Retention Schedule: This form will be retained at the County Tag Office for two years from the date issued. Print this form! Clear form ---PAGE BREAK--- MV-9D Instructions (Revised 05-2006) Instructions for Applying for a Disabled Person’s License Plate or Permanent or Temporary Permit (Placard) Except for signature(s), this application must be typed, electronically completed and printed or legibly printed by hand for signing and submission. Note: Vehicle owner information is only required when applying for a disabled person’s license plate. You do not have to own a vehicle to obtain a disabled person’s parking permit (placard). Section One *Record the vehicle owner’s full legal name, valid driver’s license number and the name of the issuing state if applying for a disabled person’s license plate. *Record the vehicle owner’s street address including the city, state and zip code if applying for a disabled person’s license plate. *Enter the county name where the vehicle owner resides if applying for a disabled person’s license plate. *Check the box to indicate the disabled person’s relationship to the vehicle owner, e.g. child, self, spouse or ward, if applying for a disabled person’s license plate. Enter the disabled person’s full legal name. Enter the disabled person’s street address including the city, state and zip code. Section Two – For Institutions Only For institutions only, enter • The institution’s full legal name • A description of the vehicle, e.g. vehicle year and make, vehicle identification number, vehicle color and vehicle license plate number • The institution’s authorized agent must sign and enter his/her position or job title with the institution. • A copy of the institutional license must be attached. Section Three Check the box(s) indicating what you are applying for, e.g. temporary parking permit (placard); permanent parking permit (placard); special permanent parking permit (placard) or disabled person’s license plate. You may apply for both a disabled person’s parking permit (placard) and a disabled person’s license plate with this form by checking the applicable boxes. Note: Disabled person’s license plates are issued to individuals, not to institutions. Section Four The practitioner of the healing arts must: Check the applicable box to indicate whether the disability is permanent or temporary. Check the applicable box to indicate the type of disability. Section Five The practitioner of the healing arts must: Print his/her full legal name, record his/her Georgia license number, sign and enter the date signed. Record his/her office street address including the city, state and zip code and his/her business telephone number, including the area code. Note: This form must be completed and signed by a licensed practitioner of the healing arts, as defined by Georgia Law §40-2-74, as amended, and his/her signature must be notarized. In addition to signing, the notary public must affix his/her notary seal or stamp and enter the date his/her notary commission expires. This application can be electronically completed and printed from our web site, www.dor.ga.gov, for signing, notarization and submission to your County Tag Agent.