The Kentucky TC 96-204 form serves as an application for a disabled person's special parking permit, facilitating access to designated parking spaces for individuals with disabilities. This form must be completed by the applicant and submitted to their County Clerk for processing. It includes sections that require verification from both the County Clerk and a licensed physician to confirm the applicant's eligibility.
The Kentucky TC 96-204 form is an essential document for individuals seeking a special parking permit designated for disabled persons. This application is managed by the Kentucky Transportation Cabinet and is crucial for ensuring that those with mobility challenges can access parking spaces that accommodate their needs. The form is divided into three main sections, each serving a specific purpose. First, applicants must provide personal details, including their name, contact information, and the vehicle identification number (VIN) of the car they own or lease. They also need to indicate whether they are applying for a license plate or a placard. In the second section, a county clerk must attest to the applicant's disability, confirming eligibility for the special parking permit. Lastly, if required, a licensed physician or an advanced practice registered nurse can provide additional certification regarding the applicant's disability. This thorough process aims to ensure that only those who genuinely need assistance can benefit from these designated parking spaces, promoting accessibility and convenience for individuals with disabilities.
Kentucky Transportation Cabinet
TC 96-204
Division of Motor Vehicle Licensing
July 2011
APPLICATION FOR DISABLED PERSON’S SPECIAL
PARKING PERMIT
(Complete and forward to your County Clerk.)
SECTION 1 – TO BE COMPLETED BY APPLICANT
Name: _____________________________________________________________________________ Phone: ________________________
Address: _______________________________________________________________________________________________________________
(Street or Post Office)(City)(State)(Zip Code)
VIN of the vehicle owned or leased by a person with a disability __________________________________________
CHECK ONE:
License Plate or Placard
Applicant now holds disabled parking license/placard No. HP _______________________________
Applicant now holds disabled veteran license/placard No. HV _______________________________
County Clerk attests that applicant is obviously disabled in Section 2 below.
A licensed physician signs statement that applicant is disabled in Section 3 below.
__________________________________________________________
(Signature of Applicant)
(Social Security)
Subscribed and sworn to before me this __________ day of _________________________________ 20 __________
My commission expires _________________________, 20 _________
________________________________________________
(Signature of Person Attesting Oath)
SECTION 2 – TO BE COMPLETED BY COUNTY CLERK
I hereby attest that the applicant is obviously disabled in compliance with KRS 186.042, and should be issued a special parking permit.
Signature of Clerk __________________________________________________________
County ________________________________
Section 3 need not be completed when Section 2 is completed.
SECTION 3 – TO BE COMPLETED BY A LICENSED PHYSICIAN OR ADVANCED PRACTICE
REGISTERED NURSE
I certify that the applicant is a person with disabilities which limit or impair the ability to walk 200 feet without stopping; without the use of assistant device; without portable oxygen; due to arthritic, neurological, or orthopedic condition; restricted by lung disease; or has a cardiac condition in compliance with KRS 186.042.
CHECK ONE: This is a
Permanent Disability
Temporary Disability
Signature of Licensed Physician/APRN _________________________________________________________________________________
Printed Name of Physician/APRN ______________________________________________ License # ______________________________
COUNTY CLERK’S USE ONLY
Previous Placard # __________________________________________________
Expires _____________________________________
New Placard # ______________________________________________________
Replacement Reason: __________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
County Clerk File Copy
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