Mississippi residents use form 76-104 to apply for a permanent or temporary disabled parking placard or a disabled license tag under Section 27-19-56 of the Mississippi Code. Section 1 is the medical certification of a qualifying walking, lung or cardiac condition. The patient then takes the one-page form to the county tax collector, who completes the issuing section.
A licensed physician or nurse practitioner completes Section 1. The county tax collector or deputy completes Section 2, and the applicant signs Section 3.
Download the current version from the source each time; forms change without notice.
Mississippi Disabled Parking Application
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Section 1 must be completed by a licensed physician or nurse practitioner, who prints their name, signs, dates and gives a phone number. The form does not provide for physician assistants or therapists to certify. The tax collector completes the rest.
Temporary placards are valid for not more than six months. On Section 1 the certifier also writes the month and year beyond which the disability should not extend, and the tax collector records the expiration date in Section 2.
With the county tax collector. Mississippi's Department of Revenue publishes the form, but the county tax collector or deputy completes Section 2 and issues the permanent placard, temporary placard or disabled license tag.