Form Mv-664.1fc - Application For A Parking Permit Or License Plates, For People With Severe Disabilities (Haitian Creole) Page 4

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NÒT POU KLIYAN YO AK PWOFESYONÈL MEDIKAL YO
Dapre Lwa Eta New York sou Veyikil ak Sikilasyon epitou dapre Lwa Penal, se yon krim (yon
deli grav oswa yon deli) pou bay fo deklarasyon oswa pou bay fo enfòmasyon nan yon fòm
aplikasyon pou yon pèmi pakin oswa pou plak imatrikilasyon pou yon moun ki gen andikap
grav. Yon moun ki fè krim sa a ka gen pou peye yon amann, li ka tonbe anba toulède pinisyon
yo. Si krim sa a konsène yon aplikasyon pou yon pèmi pakin, krim nan ka lakòz tou moun nan
responsab pou peye yon sanksyon sivil $250 - $1,000 dola.
Pou Kliyan Ki Vle Plak Imatrikilasyon, oswa yon Pèmi Pakin, pou Moun ki gen yon Andikap:
Lè ou siyen Pati 1 aplikasyon sa a, ou konfime:
enfòmasyon ou bay sou aplikasyon sa a se enfòmasyon ki vrè;
l
ou li epi konprann kondisyon yo pou “Fason pou Itilize Plak Imatrikilasyon ak Pèmi Pakin” ki endike nan
l
paj 2 a; epi
ou dakò pou respekte kondisyon sa yo.
l
Pou Pwofesyonèl Medikal Ki Bay Enfòmasyon Medikal pou Sipòte yon Aplikasyon pou Plak
Imatrikilasyon, oswa yon Pèmi Pakin, pou Moun ki gen yon Andikap:
Lè ou siyen Pati 2 aplikasyon sa a, ou konfime:
enfòmasyon medikal ou bay yo se enfòmasyon ki vrè ak konplè; epi
l
dapre sa ou konnen, moun ki gen non li endike nan Pati 1 aplikasyon an kalifye sou plan medikal pou
l
resevwa plak imatrikilasyon, oswa yon pèmi pakin, pou moun ki gen yon andikap, dapre kondisyon
medikal ki endike nan Pati 2 a.
MV-664.1FC (2/17)
dmv.ny.gov
PAJ 4 / 4

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