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New Renewal (placard). Apply at the Tag Office in the county in Georgia where you reside. *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 Driver’s License # & Name of Issuing State(if applicable) Disabled Person’s Street Address including City, State & ZIP Active Military Duty Retired GA Veteran Institution’s Full Legal Name (Institution as defined by Georgia Law §31-7-1)- Attach a copy of institutional license 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 Disabled Person’s License Plate with this form. Temporary Parking Permit (Placard) No Fee-Termination date of disability: 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). Is disability permanent? Yes No-Temporary permits shall be issued for no more than 180 days I hereby swear and affirm that the above individual as defined by Georgia Law §24-9-101 and §460-6-221(5): Is so ambulatory disabled that he/she cannot walk 200 feet without stopping to rest. Cannot walk without use of 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 severely limited in his/her ability to walk due to an arthritic, neurological, orthopedic condition or complications due to pregnancy. Is hearing impaired pursuant to Georgia Law §24-9-101. accompanied by a limit to the field or vision in the better eye to such degree that is widest diameter subtends and angle of no greater than twenty-degrees(20). Licensed Doctor’s Printed Name Doctor’s License # State of Issuance Signature Office Street Address including City, State & ZIP Telephone # including area code Note: Notarization Required For Licensed Doctor’s Signature Sworn to and subscribed before me This day of (Day) (Month) (Year) Notary Public’s Signature & Notary Seal or Stamp Date My Notary Commission Expires County and State Use Only * Retention Schedule: This form will be retained at the County Tag Office for two years from the date issued. Disabled Person’s Parking Permit # motor.etax.dor.ga.gov Is 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 Section Five - Certification Section Four - To be completed by a licensed doctor of medicine, osteopathic medicine, podiatrist, optometrist or a licensed chiropractor. 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 Vehicle Year & Make Vehicle Identification # Vehicle Color Vehicle Tag # Section Two - For Institutions Only: This vehicle is used primarily for the transportation of disabled persons. MV-9D (rev. 1-2013) Disabled Person’s Parking Affidavit * Vehicle Owner’s Full Legal Name * Driver’s License # & Name of Issuing State (person operating vehicle) Print Clear