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Missouri Form 1776: Physician's Statement for Plates

Missouri requires Form 1776 for new applicants for disabled person license plates or placards, and every eighth year at renewal. The certifier selects each qualifying disability defined in Section 301.142.1, RSMo, and marks it permanent or temporary. The statement is valid for 90 days and goes in with the Department of Revenue application.

Who completes it

The licensee fills in the patient's information and their own details, selects the disabilities and personally signs. Eligible certifiers are licensed physicians, APRNs, physician assistants, chiropractors, podiatrists, optometrists, physical therapists and occupational therapists.

Submitting and payment

How to submit it
The applicant submits the statement with Form 2769 (placard) or the plate application at a license office or by mail to the Motor Vehicle Bureau, within 90 days of signing.
Who pays
The form does not address payment for completing the physician's statement.

Good to know

  • Missouri's walking threshold is 50 feet: the person cannot walk 50 feet without stopping to rest due to a severe and disabling arthritic, neurological, orthopedic or other condition.
  • Temporary disabilities need an expiration date no more than 180 days out; without one, the placard is issued for only 30 days. One 180-day renewal needs a new Form 1776.
  • Stamped signatures and a nurse's signature are not accepted. The signer certifies that they physically examined the person.
  • The signer keeps a copy in the chart with documentation that objectively confirms the condition, and those records are open to the licensing board for review.

Get the official form

Download the current version from the source each time; forms change without notice.

Physician's Statement for Disabled License Plates or Placards

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can sign Missouri Form 1776?

Licensed physicians, advanced practice registered nurses, physician assistants, chiropractors, podiatrists, optometrists, physical therapists and occupational therapists. Chiropractors, podiatrists and optometrists may certify only conditions they are legally authorized to diagnose and treat. The signature must be personal, not stamped or signed by a nurse.

How long is Missouri Form 1776 valid?

The statement is valid for 90 days from signing. For a temporary disability, the certifier also sets an expiration date for the placard that cannot exceed 180 days; if no date is given, the temporary placard is issued for only 30 days.

Does age qualify someone for Missouri disabled plates?

No. Form 1776 states that age is not a factor in determining a disability. The certifier must select at least one condition defined in Section 301.142.1, RSMo, and other disabilities do not qualify the applicant for plates or placards.