VTR-214 (Rev. 06/11) Page 1 of 2

Application for Persons with Disabilities Parking Placard and/or License Plate

Receipt of statutory fee acknowledged License plate issued Parking Placard(s) issued County # Date

County Use Only

Complete application, submit payment (if required) in the form of a personal check, money order or cashier's check to your local County Tax Assessor-Collector's office. Do not mail cash. w Disabled Person license plates displaying the International Symbol of Access (ISA) permanent disability (limit one set of PLATES) may be issued to persons with a

w Parking placards may be issued to persons with a permanent or temporary disability. There is no fee for a placard issued to a person with a permanent disability, and a $5 fee (per placard) if issued to a person with a temporary disability w Limit one [1] placard for persons with Disabled Person license plates. Limit two [2] placards for persons with no Disabled Person license plates

Check applicable box:
One (1) Parking PLACARD Two (2) Parking PLACARDS Disabled Person PLATE(S) Disabled Person PLATE(S) and one Parking PLACARD

If you apply for a parking placard on behalf of a disabled person, include the disabled person's Texas Driver License number (DL #) or Texas DPS Identification Card number (ID #) on this application. Active duty U.S. military may list an out-of-state Driver License number.

Person with disability or Institution - Type or print only
Last Name or Institution Name Address Day Phone City DL # or ID # of Person w/ Disability E-mail First Name State Middle Initial Zip Code

Statement - State law makes falsifying information on this application a third-degree felony.
Please include your Texas Driver License number (DL #) or Texas Identification Card number (ID #) on this application. If you apply for a placard on behalf of a person with a disability, it is recommended that you include the disabled person's DL or ID # on this application in the field above. The DL or ID # provided on this application will be shown on the placard. My signature indicates that I am the person with a disability listed above, or: making application on behalf of a person with a disability - Include your DL # or ID # only if no DL or ID # is shown above the administrator or manager of an institution licensed to transport persons with disabilities defined under Transportation Code §681.0032 - Driver License # Institution, facility or retirement community must list the Facility ID number issued by DADS: Printed Name Signature

License Plates - Complete this section only if you are applying for Disabled Person license plates.
Year Year Make Make TX License Plate TX License Plate Vehicle Identification Number Vehicle Identification Number

For Disabled Person license plates, your annual vehicle registration and other applicable fees must be paid to your County Tax Assessor-Collector.

Additional set of Disabled Person PLATES for specially equipped vehicle(s) (2 tons or less) listed below:

Original - Customer

Copy - Tax Assessor-Collector

FORM VTR-214 Page 1 of 2

Online Form at www.txdmv.gov

VTR-214 (Rev. 06/11) Page 2 of 2

THIS SECTION TO BE COMPLETED BY A LICENSED PHYSICIAN*, PODIATRIST, OR OPTOMETRIST: *Or physician's assistant, which may include an Advanced Practice Nurse as defined in Chapter 301, Occupations Code. The following conditions must be met by the physician, qualifying PA, podiatrist, or optometrist: w Must be licensed in Texas, Arkansas, Louisiana, New Mexico, Oklahoma, or w Must practice medicine in a U.S. military installation based in Texas, or w Must practice medicine in a hospital or health facility of the U.S. Department of Veterans Affairs I certify that has a permanent, or temporary disability.

Name of person with a disability – type or print

Definitions State law Section 681.001(2) defines a disability as a condition in which a person has (a) mobility problems that substantially impair the person's ability to ambulate; (b) visual