Fillable NYC disability parking permit Form in PDF

Please note: An application may also be submitted on behalf of an applicant by a spouse, domestic partner as defined in the New York City Administrative Code 1-112(21), parent, guardian, or other individual having legal responsibility for the administration of such person’s day to day affairs. Please enter designee information in Section D of the applicant’s personal history page. Please note the name on the application is required to appear exactly the same as it appears on the identification document. Incomplete applications will be returned.

What will happen after my application is received?

The PPPD Unit will review all documentation to make sure your application is complete. If the application is considered incomplete, they will return the information with a letter describing the missing information needed.

The PPPD office will submit your completed application to DOHMH’s Medical Certification Unit for review. A NYC designated physician will review this application and the supporting medical documents that records your severe impaired or limited ability to walk based on the information you provided that supports a severe impaired mobility as defined in Section 16-02 of Title 24 of the Rules of the City of New York. If the supporting medical documents meet the criteria, DOHMH will certify your supporting medical documents and PPPD will issue you a permit.

If the medical documents reviewed do not meet the criteria DOHMH cannot certify and PPPD will mail you a letter with an explanation of the appeal process.

Please note that the entire application process could take up to ninety (90) days.

All information submitted with this application, and any subsequent medical documentation that the applicant submits to DOHMH, will be kept confidential and will only be shared with those involved in the certification and/or permit process to the extent permitted or required by law.

If you have any questions regarding this application, you may call Customer Service at: (718) 433-3100, for TTY call (212) 504-4115.

If you have any questions about the supporting medical documents please contact the medical certification unit at (347) 396-6552.

We appreciate the opportunity to serve you and thank you for your cooperation.

New York residents may obtain a Voter Registration Form online at: vote.nyc.ny.us or call the Board of Elections:

(212) 868- 3692 Phone Bank: (866) VOTE-NYC. Government services are not conditioned on being registered to vote.

New York City Department of Transportation

NEW YORK CITY SPECIAL PARKING IDENTIFICATION PERMIT

PARKING PERMITS FOR PEOPLE WITH DISABILITIES (PPPD)

Application for a CITY Disability Parking Permit

IDENTIFICATION DOCUMENT: Please attach a copy of your State Issued Driver License or Non-Driver Identification Card; or NYC Municipal ID (IDNYC)

B. LICENSE PLATE(S): You must submit a current copy of the passenger vehicle registration(s) for each license plate number(s) listed. Please be advised passenger vehicle registration(s) you submit will be checked for New York City parking violations, any plate(s) with outstanding parking violation judgment(s) will not be printed on your permit. Only three (3) license plates are allowed on each permit.

C. DECLARATION

I declare, under the penalties of the New York Penal Law § 210.45, that statements contained herein are, to the best of my knowledge and belief, true and correct, and that I have not knowingly and willfully made a false statement or given information which I know to be false. I understand that any information given here will be shared only with those involved in the permit process, to the extent permitted or required by law.

DATESIGNATURE OF APPLICANT*(only)

NOTE: If your identification document indicates “Unable to Sign”, please leave the above “Applicant Signature” field blank and please have your designee fill in Section D below. If you will require the services of an interpreter, please

D. DESIGNEE – If any of the statements below apply, the designee must sign.

If applicant is under 18 years old, please provide the name and telephone number of the parent, guardian, or other individual having legal responsibility for the administration of applicant’s day to day affairs.

If the applicant is 18 years old or older and is unable to sign the application and/or requires assistance in filling out this application, please provide the telephone number of the spouse, domestic partner, guardian, or other individual assisting and/or having legal responsibility for the administration of applicant’s day to day affairs.

Signature of Designee

MEDICAL HISTORY PAGE

[Disabilities that Severely Impair Ability to Walk]

NOTE: TO BE COMPLETED BY YOUR PERSONAL PHYSICIAN (M.D. or D.O.)

Name of Applicant

A NYC designated physician will review this application and the supporting medical documents based on the information you provide that supports a severe impaired mobility as defined in Section 16-02 of Title 24 of the Rules of the City of New York.

State current medical diagnosis:

AND impact on patient’s ABILITY TO WALK:

State current NEED FOR ASSISTIVE DEVICE (if any):  Cane  Walker  Wheelchair  Brace  Prosthesis  Scooter  Other

Provide supporting medical documents such as the most recent exam notes/chart notes dated within one (1) calendar year that describes your patient’s severe impaired or limited ability to walk and as indicated any diagnostic reports (e.g. X- Ray report, CT reports, MRI reports, EKG/Stress Test reports, PFT reports, EMG results, Six Minute Walk Test) to submit with this application. NO MEDICAL CDs or FILMS will be accepted.

Date of last examination: - -ATTACH EXAM NOTE

In your medical opinion, does this person have a disability that severely impairs their ability to walk and requires the use of a private automobile for transportation?

 Yes  No

Personal Physician’s Certification of the Applicant:

I affirm that I have personally examined the above named applicant and that the information presented in this application relating to this person’s walking disability is accurate.

By signing below you are certifying that the information you are providing is true and complete, any false written statements may be punishable under section 210.45 of the NYS Penal Law. In addition, any of your written false statements may be reported to the NYS Department of Health Office of Professional Medical Conduct.

New York City Department of Transportation

NEW YORK CITY SPECIAL PARKING IDENTIFICATION PERMIT PARKING PERMITS FOR PEOPLE WITH DISABILITIES (PPPD)

CHECKLIST for a CITY Disability Parking Permit

To ensure completion of your application, please read all instructions on the City application and the medical history page.

All applicants: If any information listed below is missing, your application will be mailed back to you:

1.Did you attach a copy of your identification document (a state- issued Driver License, Non-Driver Identification Card; or, NYC Municipal ID card a.k.a IDNYC)? [See What documentation must I provide for a PPPD permit? on Page 1, Instructions]

2.Did you attach a copy of your passenger vehicle registration(s) for each license plate that would appear on the City permit? Are they all current (i.e. not expired)? [See What type of vehicle information is required? on Page 1, Instructions]

3.Are all of your passenger vehicle registration(s) current (i.e., not expired)? [See What type of vehicle information is required? on Page 1, Instructions]

4. Did you check to make sure that the name and address on your application matches the address on your identification card?

5.Does the name on your supporting medical documentation match the name(s) listed on your Medical History Page? [see Medical History, Page 4]

6.Did your doctor completely fill out the applicant’s medical information, including signing and dating the medical history page? [see Medical History, Page 4]