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Application For A Metered Parking Waiver For Persons With Severe Disabilities MV-664.1MP-MV-664.2MP - New York
| Application For A Metered Parking Waiver For Persons With Severe Disabilities Form. This is a New York form and can be used in Department Of Motor Vehicles Statewide . |
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New York State Department of Motor Vehicles APPLICATION FOR A METERED PARKING WAIVER FOR PERSONS WITH SEVERE DISABILITIES METERED PARKING Instructions for completing this application are on page 2. Take the completed application to the issuing agent in the area where you live. Please bring your New York State driver license with you when you apply for the waiver. INFORMATION ABOUT PERSON WITH DISABILITY -- (Please print, and sign by the arrow.) Last Name First M.I. Date of Birth Telephone No. ( ) Male Female Address: No. and Street Apt. No. City State Zip Code Driver License Number and Expiration Date: __________________________________________________________ Do you have license plates for persons with disabilities? No Yes, plate number is:_____________________ No Yes, permit number is:____________________ Do you have a parking permit for persons with disabilities? By signing this form I certify that I meet the requirements for a metered parking waiver. I understand that making a false statement or providing misinformation on an application to obtain or facilitate the receipt of a metered parking waiver for people with disabilities may result in a civil penalty ranging from $250-$1,000 and/or criminal prosecution and penalties. (Signature of Person with Disability or Signature of Parent or Guardian) -- If signed by a parent or (Date) guardian, please state your relationship to the person with the disability after your signature. MEDICAL CERTIFICATION--This section must be completed only by a Medical Doctor (MD) or Doctor of Osteopathy (DO). The metered parking waiver is available to people who are severely disabled as defined in Vehicle and Traffic Law Section 404-a (see Part A) AND who also have a disability that hinders their ability to put payment into a parking meter (see Part B). ! Part A Uses portable oxygen Legally blind Limited or no use of one or both legs Unable to walk 200 ft. without stopping Neuromuscular dysfunction that severely limits mobility Class III or IV cardiac condition. (American Heart Association standards) Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition Restricted by lung disease to such an extent that forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one liter, or the arterial oxygen tension is less than sixty mm/hg of room air at rest Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability, and which imposes unusual hardship in the use of public transportation and prevents the person from getting around without great difficulty. Please certify that the severely disabled patient (as described in Part A) also has a severe disability that limits one or more of the following (check all that apply): Fine motor control of both hands Ability to reach or access a parking meter due to use of a wheel-chair or other ambulatory device Ability to reach a height of forty-two inches from the ground due to lack of finger, hand, or upper extremity strength or mobility. Professional License No. Telephone No. ( ) ! Part B MD/DO Name (Print/Type) MD/DO Address (Print/Type) By signing this form I certify that this severely disabled patient (as defined by NYS Vehicle and Traffic Law Section 404-a) has a disability limiting one or more of the actions listed in Part B above. I understand that making a false statement or providing misinformation on an application to obtain or facilitate the receipt of a metered parking waiver for people with disabilities may result in a civil penalty ranging from $250-$1,000 and/or criminal prosecution and penalties. (MD/DO Signature) (Date) File Information (For Issuing Agent use Only) MV-664MP No. Issued: __________________ Date Issued:_______________ MV-664 No. Issued: ____________________ MV-664.1MP (1/11) PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com New York State Department of Motor Vehicles INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR A METERED PARKING WAIVER The metered parking waiver is intended for use by those individuals whose severe disabilities make it extremely difficult to put payment into a parking meter when traveling alone. Any person who makes a false statement or gives information which is known to be false to a public official to obtain a metered parking waiver may be subject to a civil penalty of $250-$1,000 and possible criminal prosecution. STEP 1 - Metered Parking Waiver Requirements In order to be eligible for the metered parking waiver, you must meet all of the following conditions: 1. Be a resident of New York State; and 2. Be a resident of the city, town, or village in which you are obtaining the waiver; and 3. Hold a valid New York State driver license; and 4. Are severely disabled as defined in Vehicle and Traffic Law Section 404-a (see Part A on page 1); and 5. Your severe disability as certified by a licensed physician limits one or more of the following: a. Fine motor control in both hands; or b. Ability to reach or access a parking meter due to use of a wheelchair or other ambulatory device; or c. Ability to reach a height of 42 inches from the ground due to lack of finger, hand or upper extremity strength or mobility Do you meet all of the requirements listed above in 1-5? If No, you are not eligible for a metered parking waiver. If Yes, continue on to Step 2. STEP 2 - Complete the section "Information About Person with Disability". · · Clearly print your personal information in the boxes provided. Print your New York State driver license number and expiration date in the space provided. Your driver license number is the 9 digit ID number located near your picture. The expiration date is printed in red on the bottom of the license. This number needs to be a date in the future. If you have license plates with the International Symbol of Access, check "Yes" and write your plate number in the space provided. If you do not have those plates, check "No". If you have a permanent (blue) parking permit for people with severe disabilities, check "Yes" and write the permit number in the space provided. The permit number is a 6 or 7 digit number printed in black along the top portion of the permit. If you do not have a permanent permit, check "No". Read the certification statement and sign the form in the space provided. · · · STEP 3 - Have your doctor fill out the Medical Certification section. · · · · Bring the application form to your medical doct
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