Form DSD X164 "Application for an Illinois Person With a Disability Identification Card" - Illinois

What Is Form DSD X164?

This is a legal form that was released by the Illinois Secretary of State - a government authority operating within Illinois. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2020;
  • The latest edition provided by the Illinois Secretary of State;
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Download Form DSD X164 "Application for an Illinois Person With a Disability Identification Card" - Illinois

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State of Illinois • Secretary of State
Application for an Illinois Person with a Disability Identification Card
I am applying for an Illinois Person with a Disability Identification Card at no fee on the basis that I am an indi-
vidual who is disabled as defined in Section 4A of the Illinois Identification Card Act. This report shall remain valid
for three months.
I affirm that the information in this affidavit is true and correct.
Applicant's Signature/Date _____________________________________________________________________________________
Driver’s License Number
and/or
Identification Card Number
___________________________________________________
_________________________________________________
___________________________________________________
_________________________________________________
Witness
Witness
Certification for Illinois Person with a Disability Identification Card
Below please indicate the Priority of the Type of Disability and the corresponding Classification of Disability pertain-
ing to the applicant named on this affidavit. Refer to the Definition Supplement on the reverse for assistance. (Please
mark on the lines provided, any type and classification applicable, in priority order using a 1 to 5 numbering scale.
NOTE to Physician: The numbering scale begins with (1) as the lowest priority and (5) as the highest priority.
Priority:
Disability:
Class:
________
Physical (P)
_________
________
Developmental (D)
_________
________
Visual (V)
_________
________
Hearing (H)
_________
________
Mental (M)
_________
I hereby certify that the conditions of the person with disabilities named herein are determined and defined under
Chapter 15, Illinois Compiled Statutes, Section 335/4A.
__________________________________________________________
Physician’s Signature / Date
__________________________________________________________
Physician Assistant’s/Advanced Practice Nurse’s (APN) Signature / Date
(PLEASE PRINT OR TYPE BELOW)
Physician’s Name
Phone
Address
Applicant’s Name
Date
Driver’s License or ID Number
Control Number
MISUSE OF A PERSON WITH A DISABILITY ID CARD
CAN RESULT IN ITS REVOCATION
* Please submit this completed form at your local Driver Services facility.
State of Illinois • Secretary of State
Application for an Illinois Person with a Disability Identification Card
I am applying for an Illinois Person with a Disability Identification Card at no fee on the basis that I am an indi-
vidual who is disabled as defined in Section 4A of the Illinois Identification Card Act. This report shall remain valid
for three months.
I affirm that the information in this affidavit is true and correct.
Applicant's Signature/Date _____________________________________________________________________________________
Driver’s License Number
and/or
Identification Card Number
___________________________________________________
_________________________________________________
___________________________________________________
_________________________________________________
Witness
Witness
Certification for Illinois Person with a Disability Identification Card
Below please indicate the Priority of the Type of Disability and the corresponding Classification of Disability pertain-
ing to the applicant named on this affidavit. Refer to the Definition Supplement on the reverse for assistance. (Please
mark on the lines provided, any type and classification applicable, in priority order using a 1 to 5 numbering scale.
NOTE to Physician: The numbering scale begins with (1) as the lowest priority and (5) as the highest priority.
Priority:
Disability:
Class:
________
Physical (P)
_________
________
Developmental (D)
_________
________
Visual (V)
_________
________
Hearing (H)
_________
________
Mental (M)
_________
I hereby certify that the conditions of the person with disabilities named herein are determined and defined under
Chapter 15, Illinois Compiled Statutes, Section 335/4A.
__________________________________________________________
Physician’s Signature / Date
__________________________________________________________
Physician Assistant’s/Advanced Practice Nurse’s (APN) Signature / Date
(PLEASE PRINT OR TYPE BELOW)
Physician’s Name
Phone
Address
Applicant’s Name
Date
Driver’s License or ID Number
Control Number
MISUSE OF A PERSON WITH A DISABILITY ID CARD
CAN RESULT IN ITS REVOCATION
* Please submit this completed form at your local Driver Services facility.
Definition Supplement
Chapter 15, Illinois Compiled Statutes, Section 335/4A defines:
Types of Disabilities
Type One: Physical (P)
A physical disability is a physical impairment, disease, or loss, which is of a permanent nature, and which substantially
limits physical ability or motor skills.
Type Two: Developmental (D)
Developmental disability means a disability that is attributable to: (i) an intellectual disability, cerebral palsy, epilepsy,
or autism or (ii) any other condition that results in impairment similar to that caused by an intellectual disability and
requires services similar to those required by persons with intellectual disabilities. Such a disability must originate
before the age of 18 years, be expected to continue indefinitely, and constitute a substantial handicap.
Type Three: Visual (V)
A visual disability is blindness, and the term “blindness” means central vision acuity of 20/200 or less in the better eye
with the use of a correcting lens. An eye that is accompanied by a limitation in the fields of vision so that the widest
diameter of the visual field subtends an angle no greater than 20 degrees shall be considered as having a central vision
acuity of 20/200 or less.
Type Four: Hearing (H)
A hearing disability is a disability resulting in complete absence of hearing, or hearing that with sound enhancing or
magnifying equipment is so impaired as to require the use of sensory input other than hearing as the principal means
of receiving spoken language.
Type Five: Mental (M)
A mental disability is a significant impairment of an individual’s cognitive, affective, or relational abilities that may require
intervention and may be a recognized, medically diagnosable illness or disorder.
Classifications of Disabilities
Class 1
A Class 1 disability is any type of disability which does not render a person unable to engage in any substantially gainful
activity, or which does not impair the person’s ability to live independently or to perform labor or services for which
he/she is qualified.
Class 1a
A Class 1a disability is a Class 1 disability which renders a person unable to walk 200 feet or more unassisted by another
person or without the aid of a walker, crutches, braces, prosthetic device or a wheelchair, or without great difficulty or
discomfort due to the following impairments: neurologic, orthopedic, oncological, respiratory, cardiac, arthritic disorder,
blindness, or the loss of function or absence of a limb or limbs.
Class 2
A Class 2 disability is any type of disability which renders a person unable to engage in any substantially gainful activity,
or which substantially impairs the person’s ability to live independently without supervision or in-home support services,
or which substantially impairs the person’s ability to perform labor or services for which he/she is qualified or signifi-
cantly restricts the labor or services which he/she is able to perform.
Class 2a
A Class 2a disability is a Class 2 disability which renders a person unable to walk 200 feet or more unassisted by another
person or without the aid of a walker, crutches, braces, prosthetic device or a wheelchair, or without great difficulty or
discomfort due to the following impairments: neurologic, orthopedic, oncological, respiratory, cardiac, arthritic disorder,
blindness, or the loss of function or absence of a limb or limbs.
Printed by authority of the State of Illinois. July 2020 — 10M — DSD X 164.6
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