Form Reg 195 - Application For Disabled Person Placard Or Plates
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1
2APPLICATION FOR
DISAbLED PERSON PLACARD OR PLATES
A Public Service Agency
(NOTE: For lost, stolen, or mutilated disabled person or disabled veteran license plates or placard, please complete an Application For
Replacement Plates, Stickers, and Documents [form REG 156 available on DmV Web]).
Please check at least one of the following boxes:
Disabled Person License Plates
No Fee
Permanent Parking Placard
NOTE: Disabled Person license plates can only be assigned to vehicles
No Fee
currently registered in the name of the qualified disabled person.
Temporary Parking Placard
$6
Travel Parking Placard
No Fee
Travel Parking Placards are issued to applicants with permanent disabilities. A California resident, applying for a Travel Parking Placard,
must have a permanent parking placard or disabled person or disabled veteran license plates, but not both. Travel Parking Placards are
issued to non-residents for no more than 90 days and to California residents for no more that 30 days.
.
All applicants must complete sections A, b and E. Disabled Person License Plate applicants must also complete section C
A.
APPLICANT’S TRuE FuLL NAME (PLEASE PRINT)
LAST NAmE FIRST NAmE mIDDLE NAmE OR ORGANIzATION NAmE
DATE OF bIRTh (NOT REqUIRED FOR ORGANIzATIONS)
month
Day
Year
RESIDENCE OR ORGANIzATION ADDRESS APT/SPACE
DRIVER LICENSE/ID NUmbER (NOT REqUIRED FOR ORGANIzATIONS)
CITY
STATE
zIP CODE
DAYTImE TELEPhONE NUmbER
( )
mAILING ADDRESS
APT/SPACE
CITY
STATE
zIP CODE
b.
Were you ever issued Disabled Person or Disabled Veteran License Plates or a Permanent Parking Placard in California?
yES – A doctor’s disability certification is NOT required, unless the placard was canceled by the department or is no longer on
record. The disabled person or veteran license plates or permanent placard number is ________________________________ .
NO – A doctor’s certification is required. The doctor must complete sections F and G on the reverse side.
C.
IF yOu ARE APPLyING FOR DISAbLED PERSON LICENSE PLATES, please describe the vehicle that is registered to you on
which you will put the disabled person license plates:
LICENSE PLATE NUmbER
VEhICLE IDENTIFICATION NUmbER
mAkE
CoMMerCIaL VehICLe exeMPTIon
I am requesting an exemption from weight fees for the vehicle described above. It weighs less than 8,001 pounds unladen and is the only
commercial vehicle for which I have requested this exemption.
Yes
No
D.
IMPORTANT INFORMATION – PLEASE READ
IT IS ILLEGAL
• To allow someone to use your placard, if you are not in the vehicle.
• To possess or display a counterfeit placard.
• For an individual to have more than one permanent placard.
• To alter a placard or placard identification card.
• To provide false information to obtain a placard or disabled person plates.
• To forge a doctor’s signature.
IMPORTANT
• The only legal use of a placard is its display by the person to whom it is issued. The disabled person does not have to own or drive the
vehicle to use the placard.
• Placard abuse or misuse can result in the cancellation and revocation of the placard and loss of the privileges it provides.
• Placard and disabled person license plate abuse is a misdemeanor punishable by a fine of not less than $250, not more than $1,000, or
by imprisonment in a county jail for not more than 6 months, or by both fine and imprisonment. The court may also impose a civil penalty
of not more than $1,500, for each conviction.
• To alter, forge, counterfeit or falsify a plate is a felony punishable by 16 months to 3 years in a state prison or up to 1 year in the county jail.
• A person who forges, counterfeits, falsifies or passes, attempts to pass, acquires, possesses, sells, or attempts to sell a genuine or
counterfeit placard, or a person who displays with fraudulent intent, or causes or permits to be displayed a forged, counterfeit or false
placard is guilty of a misdemeanor and upon conviction shall be punished by imprisonment in the county jail for 6 months or by a fine of
not less than $500 or more than $1,000, or by both fine and imprisonment. The court may also impose a civil penalty of not more than
$3,500 for each conviction.
• The plate and/or placard must be surrendered to DMV within 60 days of the death of the disabled person.
• Any information contained in this application will be available to local public law enforcement or the local agencies responsible for the
enforcement of parking regulations.
E.
APPLICANT’S SIGNATuRE AND CERTIFICATION
I have read the “Important Information” in section D and I fully understand and take responsibility for the use of the
disabled person placard or plates that are issued to me.
I certify (or declare) under penalty of perjury under the laws of the State of California that all the foregoing is true and correct. I also certify
that I am a disabled person per CVC 295.5 (as defined in section F) and that I am
Permanently or
Temporarily disabled due to: _____________________________________________________________ .
EXECUTED AT (CITY, STATE)
DATE
SIGNATURE OF APPLICANT
REG 195 (REV. 8/2008) WWW
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