Check appropriate blocks below (request type)
The applicant checks an original request (permanent placard, severely disabled veteran or temporary placard), a renewal of a permanent placard, a replacement of a placard or ID card that was defaced, lost, stolen or never received, or a change of address or name. The request type sets which sections are needed: a permanent placard needs A, B or C, and E; a temporary placard needs A, B and E.
A: Person with Disability Information
The applicant enters name, PA driver's license or photo ID number, date of birth, address and email; organizations enter a business name and ID number such as an EIN. An out-of-state address requires form MV-8. A parent, person in loco parentis or spouse acting for the applicant adds their name, relationship and address here.
B: Certification from a Health Care Provider Licensed or Certified in PA or a Contiguous State
The provider certifies the person is under their care and lists the reason code from the reverse. For code 1, complete the uncorrected and corrected visual acuity chart for right, left and both eyes; for code 4, name the device. Then add printed name, signature, office address, medical license number and telephone. The form says this section must be completed in full, and temporary placards last no more than six months.
Eligibility Requirements (Reason Codes)
The applicant (1) is blind; (2) lacks full use of an arm or both arms; (3) cannot walk 200 feet without resting; (4) cannot walk without a brace, cane, crutch, another person, prosthesis, wheelchair or other device; (5) has lung disease with FEV1 under one liter or resting arterial oxygen tension under 60 mm Hg on room air; (6) uses portable oxygen; (7) has an AHA Class III or IV cardiac condition; or (8) is severely limited in walking by an arthritic, neurological or orthopedic condition.
C: Certification by Police Officer
A police officer may certify only that the applicant is blind or does not have full use of a leg or both legs, shown by a wheelchair, walker, crutches, cane or quad cane, or other prescribed device. The officer signs with badge number and office address. This section is skipped when Section B is completed, and it cannot be used for a temporary placard.
D: Certification from U.S. Department of Veterans Affairs Regional Office Administrator
Used for the Severely Disabled Veteran placard. An authorized VA official in Philadelphia or Pittsburgh, or the veteran's service unit, enters the VA number and certifies a 100% service-connected disability or a service-connected reason code, naming the device for code 4. A legible copy of the veteran's benefits letter showing 100% service connection can replace the signature.
E: Unsworn Declaration and Applicant Signature
The person with the disability, natural parent or other authorized person signs, dates and gives the county or location of signing, declaring under penalty of perjury that the application is true. Statements are subject to the penalties for unsworn falsification under 18 Pa.C.S. Section 4904. Every request type requires this section.