Form MV-9D "Person With Disability Parking Placard/License Plate Application" - Georgia (United States)

What Is Form MV-9D?

This is a legal form that was released by the Georgia Department of Revenue - a government authority operating within Georgia (United States). As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the Georgia Department of Revenue;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MV-9D by clicking the link below or browse more documents and templates provided by the Georgia Department of Revenue.

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Download Form MV-9D "Person With Disability Parking Placard/License Plate Application" - Georgia (United States)

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MV-9D (Revised 1-2019)
PRINT
CLEAR
Web and MV Manual
Georgia Department of Revenue - Motor Vehicle Division
Person with Disability Parking Placard/License Plate Application
Purpose of this form: This form is to be used to request a Person with Disability Parking Placard or a Disabled Person’s License Plate. This form should not be
used to record a change of ownership, change of address, or change of license plate classification.
How to submit this form: After reviewing the MV-9D form instructions, this fully completed form must be submitted to your local County tag office. Please refer to
our website at
https://dor.georgia.gov
to locate the address(es) for your specific county.
A
REQUEST TYPE
Check applicable box(es) below:
Placard No.: Record placard number if
[
] Disabled Person’s Parking Permit (Placard):
renewing or replacing placard.
[
] New Issuance: [
] Temporary Placard [
] Permanent Placard [
] Special Permanent Placard
[
] Renewal (Permanent Placards Only)
Record placard number 
[
] Replacement: [
] Lost [
] Stolen
Record previous placard number 
[
] Disabled Person’s License Plate Fee: $20.00 Plate Fee plus any taxes that maybe due. Please Note: Section D must be completed and notarized.
B
APPLICANT INFORMATION
Disabled Person’s
First Name
Middle Initial
Last Name
Suffix
Telephone No.:
Full Legal Name:
Street No.
Street Name
Apt./Suite No.
City
State
ZIP Code
Physical Address:
Driver’s License No.:
State of Issuance:
County:
C
PARENT/GUARDIAN INFORMATION
Note: If you are the parent or adult charged by law with the natural parent’s rights, duties and responsibilities acting on behalf of a minor child
(under 18) in place of the child’s natural parents (person in loco-parentis), you must complete the information below.
Parent/Guardian’s
First Name
Middle Initial
Last Name
Suffix
Relationship
Full Legal Name:
to Applicant:
Street No.
Street Name
Apt./Suite No.
City
State
ZIP Code
Physical Address:
Driver’s License No.:
State of Issuance:
County:
D
CERTIFICATION FROM A LICENSED OR CERTIFIED HEALTH CARE PROVIDER
I hereby certify that the person with the disability listed above is under my care and has the following condition listed on the reverse side of this application under
“Eligibility Requirements.” Enter Reason Code No.:
(Note: Only those conditions listed on the reverse side of this application qualify
an applicant for a Person with Disability Parking Placard.) **PLEASE SEE INSTRUCTIONS BEFORE COMPLETING**
Sworn to and subscribed before me
Health Care Provider’s Name:
this ____ day of _______________, ______
Medical License No.:
Day
Month
Year
Notary Seal or Stamp
Street No., Street Name, Suite No.
City, State, ZIP Code
Physical Address:
____________________________________
Notary Signature
____________________________
Telephone No.:
Signature:
Commission Expiration Date
E
INSTITUTION/BUSINESS INFORMATION (This vehicle is used primarily for transportation of disabled persons.)
Institution/Business
FEIN:
Full Legal Name:
Vehicle Identification No.:
Year:
Make:
Model:
Tag No.:
Authorized Representative’s
Position/ Job Title:
Printed Name:
Authorized Representative’s
/
/
Date:
Signature:
F
APPLICANT SIGNATURE
I state that I have read and signed this application after its completion, and I swear or affirm that the statements made herein are true and correct, and I
acknowledge that any person knowingly or willfully making a false statement on or pursuant to this application is guilty of a misdemeanor under Georgia Code
§40-2-74(a.1).
/
/
Signature:
Date:
Have a question? Visit our website at
https://dor.georgia.gov/motor-vehicles
or scan the QR code above for more information.
MV-9D (Revised 1-2019)
PRINT
CLEAR
Web and MV Manual
Georgia Department of Revenue - Motor Vehicle Division
Person with Disability Parking Placard/License Plate Application
Purpose of this form: This form is to be used to request a Person with Disability Parking Placard or a Disabled Person’s License Plate. This form should not be
used to record a change of ownership, change of address, or change of license plate classification.
How to submit this form: After reviewing the MV-9D form instructions, this fully completed form must be submitted to your local County tag office. Please refer to
our website at
https://dor.georgia.gov
to locate the address(es) for your specific county.
A
REQUEST TYPE
Check applicable box(es) below:
Placard No.: Record placard number if
[
] Disabled Person’s Parking Permit (Placard):
renewing or replacing placard.
[
] New Issuance: [
] Temporary Placard [
] Permanent Placard [
] Special Permanent Placard
[
] Renewal (Permanent Placards Only)
Record placard number 
[
] Replacement: [
] Lost [
] Stolen
Record previous placard number 
[
] Disabled Person’s License Plate Fee: $20.00 Plate Fee plus any taxes that maybe due. Please Note: Section D must be completed and notarized.
B
APPLICANT INFORMATION
Disabled Person’s
First Name
Middle Initial
Last Name
Suffix
Telephone No.:
Full Legal Name:
Street No.
Street Name
Apt./Suite No.
City
State
ZIP Code
Physical Address:
Driver’s License No.:
State of Issuance:
County:
C
PARENT/GUARDIAN INFORMATION
Note: If you are the parent or adult charged by law with the natural parent’s rights, duties and responsibilities acting on behalf of a minor child
(under 18) in place of the child’s natural parents (person in loco-parentis), you must complete the information below.
Parent/Guardian’s
First Name
Middle Initial
Last Name
Suffix
Relationship
Full Legal Name:
to Applicant:
Street No.
Street Name
Apt./Suite No.
City
State
ZIP Code
Physical Address:
Driver’s License No.:
State of Issuance:
County:
D
CERTIFICATION FROM A LICENSED OR CERTIFIED HEALTH CARE PROVIDER
I hereby certify that the person with the disability listed above is under my care and has the following condition listed on the reverse side of this application under
“Eligibility Requirements.” Enter Reason Code No.:
(Note: Only those conditions listed on the reverse side of this application qualify
an applicant for a Person with Disability Parking Placard.) **PLEASE SEE INSTRUCTIONS BEFORE COMPLETING**
Sworn to and subscribed before me
Health Care Provider’s Name:
this ____ day of _______________, ______
Medical License No.:
Day
Month
Year
Notary Seal or Stamp
Street No., Street Name, Suite No.
City, State, ZIP Code
Physical Address:
____________________________________
Notary Signature
____________________________
Telephone No.:
Signature:
Commission Expiration Date
E
INSTITUTION/BUSINESS INFORMATION (This vehicle is used primarily for transportation of disabled persons.)
Institution/Business
FEIN:
Full Legal Name:
Vehicle Identification No.:
Year:
Make:
Model:
Tag No.:
Authorized Representative’s
Position/ Job Title:
Printed Name:
Authorized Representative’s
/
/
Date:
Signature:
F
APPLICANT SIGNATURE
I state that I have read and signed this application after its completion, and I swear or affirm that the statements made herein are true and correct, and I
acknowledge that any person knowingly or willfully making a false statement on or pursuant to this application is guilty of a misdemeanor under Georgia Code
§40-2-74(a.1).
/
/
Signature:
Date:
Have a question? Visit our website at
https://dor.georgia.gov/motor-vehicles
or scan the QR code above for more information.
INSTRUCTIONS
How to complete the MV-9D Form
COMPLETING THIS FORM
Temporary Placard: Complete Sections A, B, C, D and F. Note: Only licensed health care providers may certify disabilities for temporary placards. Temporary
placards may not be extended for an additional period of time. When additional time is needed, a new application must be completed and certified by a health
care provider. In addition, please list your previous placard number. Temporary placards are only issued for a period of time not to exceed six months.
Permanent Placard: Complete Sections A, B, C, D and F. Note: Individuals should list their Georgia Driver’s License number or Photo ID number in the space
provided. Businesses should list their Business ID number (Bus. ID) where indicated (i.e., E.I.N.) and provide a copy of business license.
Special Permanent Placard: Follow the instructions for a Permanent Placard. A Special Permanent Placard (gold placard) is issued only to an individual with a
disability who (1) drives a motor vehicle equipped with hand controls for the operation of brakes and accelerator or (2) is disabled due to loss, or loss of use, of
both upper extremities.
Renewal Request: Complete Sections A, B and F. Note: Notarization is not required.
Replacement Request: Indicate if applying for a replacement placard. Please check reason for replacement (Lost or Stolen). List your previous placard number
and complete Sections A, B and F.
Institution/Business Information: Complete Sections A, B, E and F. Follow these additional special instructions:
• Institutions, as defined by Georgia Code §31-7-1, must attach a copy of the institutional license. Note: To qualify for a permit, the institution must operate
the vehicle primarily to transport individuals with disabilities.
• Businesses, to qualify for a special plate, must meet the requirements of Georgia Code §40-2-74, including limits on the type of business organization.
Note: The business vehicle must be used only or primarily by the disabled employee for whom the plate was issued.
Please Note:
• A placard is to be used only when the vehicle in which it is displayed is parked and is being used for the transportation of the person with disability or the
severely disabled veteran.
• Any vehicle lawfully displaying a placard will qualify for parking in areas designated for use by persons with disability only.
• The placard will not allow vehicles to park where parking is prohibited.
• The placard is required to be displayed when the vehicle is parked in areas designated for use by persons with disability only and must not be displayed
when the vehicle is being operated on the highway.
• Each eligible individual will be issued only one placard.
ELIGIBILITY REQUIREMENTS – REASON CODES
1. Applicant is so ambulatory disabled that he/she cannot walk 200 feet
5. Applicant has a cardiac condition to the extent that his/her functional
without stopping to rest.
limitations are classified in severity as Class III or Class IV according to
2. Applicant cannot walk without the use of assistance from a brace, a cane, a
standards set by the American Heart Association.
crutch, another person, a prosthetic device, a wheelchair, or other assistive
6. Applicant is severely limited in his/her ability to walk due to an arthritic,
device.
neurological, orthopedic condition or complications due to pregnancy.
3. Applicant is restricted by lung disease to such an extent that his/her forced
7. Applicant is hearing impaired person pursuant to Georgia Code §24-6-651.
respiratory volume for one second, when measured by spironmetry is less
than one liter, or when at rest his/her arterial oxygen tension is less than 60
8. Applicant is a blind individual whose central visual acuity does not exceed
millimeters of mercury on room air.
20/200 in the better eye with correcting lenses or whose visual acuity, if
better than 20/200, is accompanied by a limit to the field of vision in the
4. Applicant uses portable oxygen.
better eye to such a degree that its widest diameter subtends an angle of
no greater than 20 degrees.
QUALIFYING VEHICLES
A passenger vehicle or truck with a registered gross weight of not more than 10,000 lbs. This restriction does not apply to institution or business applications.
CERTIFICATION FROM A LICENSED OR CERTIFIED HEALTH CARE PROVIDER
“For purposes of this Code section (40-2-74.1) the department shall accept, in
lieu of an affidavit, a signed and dated statement from the doctor which
includes the same information as required in an affidavit written upon security
paper as defined in paragraph (38.5) of Code Section 26-4-5."
Jane Doe
40
Please Note: Certification in lieu of an affidavit (completion and notarization of
123 Main St.
Section D) can only be submitted for placards and cannot be provided on
Secured paper document (as defined by GA Code 26-4-5) from
license plate applications.
healthcare provider must include:
Who may provide certification: Health care providers that are permitted to
• Specific disability as indicated on MV-9D instructions form.
provide a certification are limited to medical practitioners licensed to practice
• Indication of permanent or temporary disability
under Article 2 of Chapter 34 of Title 43 (physicians); Chapter 35 of Title 43
• Stamp or signature of healthcare provider
(podiatrists); and Chapter 9 of Title 43 (chiropractors) of the Georgia Code.
• Date
SAMPLE
SUBMITTING THIS FORM
After reviewing the MV-9D form instructions, this fully completed form must be submitted to your local County tag office. Please refer to our
website at
https://dor.georgia.gov
to locate the address(es) for your specific county.
Have a question? Visit our website at
https://dor.georgia.gov/motor-vehicles
or scan the QR code above for more information.
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