PennDOT - Form MV-145A

1 ORIGINAL REQUEST - Permanent Placard Severely Disabled Veteran Temporary Placard qqqqqRENEWAL REQUEST - (For Permanent Placards Only)CHECK ( 4 ) APPROPRIATE BLOCKS BELOWqqREPLACEMENT REQUEST - PLACARD ID CARD Defaced Lost Stolen Never Received CHANGE OF ADDRESS/NAME AAPPLICANT INFORMATION - LIST NAME AND ADDRESS OF PERSON WITH DISABILITYBCERTIFICATION FROM A HEALTH CARE PROVIDER LICENSED OR CERTIFIED IN PA OR A CONTIGUOUS STATE (NEW YORK, NEW JERSEY,DELAWARE, MARYLAND, WEST VIRGINIA OR OHIO).

2 THIS SECTION MUST BE COMPLETED IN FULL. HEALTH CARE PROVIDERS MAY ONLYCERTIFY DISABILITIES WITHIN THEIR SCOPE OF PRACTICE. WARNING: Altering or forging a document issued by the Department, such as adisabled person parking placard, or possessing, using or displaying, such a document knowing it to have been altered, forged or counterfeited,is a misdemeanor of the first degree pursuant to the Vehicle Code, 75 Section 7122, punishable by a fine of not more than $10,000 orimprisonment of not more than five years.

3 Or BY police OFFICER - police officer may only certify that the applicant does not have full use of a leg or both legs, or is : If Section B above is completed, please skip this Section and go on to Section FROM VETERANS ADMINISTRATION REGIONAL OFFICE ADMINISTRATOR OR HIS/HER DESIGNATED REPRESENTATIVE(Philadelphia or pittsburgh ) OR SERVICE UNIT IN WHICH THE VETERAN AND APPLICANT SIGNATURE - Applicant, natural parent or other authorized person listed in Section A must sign PLACARD # _____Last Name (or Full Business Name)Street AddressCityState Zip CodeFirst NameMiddle Name PA DL/Photo ID# orBus.

4 ID#Date of BirthNOTE: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 of Parent or Person in Loco ParentisStreet AddressCityState Zip CodeRelationship to ApplicantAge of Applicant Listedin Section AI 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 thisapplication under Eligibility Requirements : _____ (NOTE.)

5 Only those conditions listed on the reverse side of this application qualify anapplicant for a person with disability placard.)NOTE:If reason code #4 is listed above, please indicate the type of device used: _____Temporary placards are only issued for a period of time not to exceed six months. If the applicant requires additional time after the expiration of theplacard issued, the applicant must be recertified by a health care Reason Code # HereHealth Care Provider s NameOffice Street AddressCityStateZip CodeHealth Care Provider s SignatureMedical License s NameOffice Street AddressCityState Zip CodeOfficer s SignatureBadge NumberTelephone Number( )

6 This is to certify that the person with disability listed above has the condition listed and is entitled to the use and privileges of the person with disabilityparking blind,ORdoes not have full use of a leg or both legs as evidenced by the use of a crutcheswheelchair walkercane/quad caneother prescribed deviceThis is to certify that the veteran listed above with VA number _____ has service connected disabilities rated at 100% or has thefollowing service connected disability listed on the reverse side of this application under Eligibility Requirements : _____.

7 NOTE:Ifreason code #4 is listed, please indicate the type of device used: _____ .List Reason Code # HereAuthorized Signature:Title of Authorized Signer:I state that I have read and signed this application after its completion, and I swear oraffirm that the statements made herein are true and correct, and that any statementmade on or pursuant to this application is subject to the penalties of 18 PA 4903 (a)(2) (relating to false swearing), which shall include punishment of afine not exceeding $5,000, or to a term or imprisonment of not more than two years,or SignatureTelephone NumberDateMessenger No.

8 ( )SUBSCRIBED AND SWORNTO BEFORE ME: MONTH DAY YEARSIGNATURE OF PERSON ADMINISTERING OATHtSTAMPSIGN IN PRESENCE OF NOTARYTHIS APPLICATION MAY BE DUPLICATEDq q qq qqqqqqqq MV-145A (3-13) PERSON WITH DISABILITY PARKINGPLACARD APPLICATION(One Placard Per Qualified Person) NO FEE REQUIREDSEE REVERSE SIDE FOR INSTRUCTIONS AND IMPORTANT DEPARTMENT USE ONLYB ureau of Motor Vehicles Box 68268 Harrisburg, PA 17106-8268 FOR TEMPORARY PLACARD ONLY.

9 Pleasecircle expiry needed - not to exceed 6 monthsfrom certification Jun Sept DecINSTRUCTIONS1. Permanent Placard - Complete Sections A, B or C (NOT BOTH) and E. NOTE: Individuals should list their PA Driver s License (PA DL) or Photo ID# in the space provided. Businesses should list their Business ID# (Bus. ID) where indicated ( ).2. Severely Disabled Veteran Placard - Complete Sections A, D and Temporary Placard - Complete Sections A, B and E. NOTE: Only licensed health care providers* may certify disabilities for temporary placards.

10 Temporaryplacards may not be extended for an additional period of additional time is needed, a new application must be completed and certified bya health care provider. In addition, please list your previous placard Renewal Request - Complete Sections A and E. NOTE: Notarization is not Replacement Request - Indicate if applying for a replacement placard or ID card. Please check reason for replacement; Lost, Stolen, Defaced or NeverReceived. List your previous placard number and complete Sections A and E.