Form MV-400PH - Request for Custom Empire Plates - New York
New York State Department of Motor Vehicles
REQUEST FOR CUSTOM EMPIRE PLATES - DISABLED REGISTRANT
INFORMATION AND INSTRUCTIONS:
Custom Empire license plates with a combination of two to six letters and/or numbers, followed by the International Symbol of Access, are available
to qualified disabled individuals. See Part 2 below for a description of qualifying disabilities. These custom plates are available only for vehicles that
use passenger plates and for vans and pick-up trucks registered by disabled persons, and may not be used for commercial purposes. The initial fee
for these plates is $60.00. There is a $31.25 annual renewal fee for these plates in addition to your regular vehicle registration renewal fee. You will
be billed $62.50 (two $31.25 annual renewal fees) for your custom plates every two years when you renew your registration.
To obtain these plates:
1. Verify that the vehicle on which the plates will be used is registered in the name of the person with the disability.
2. Fill out Part 1 below and have the appropriate medical professional complete the medical certification in Part 2.
NOTE: A medical certification is not required if you already have plates for the disabled and want to exchange them for custom plates
for the disabled. If you currently have plates for the disabled, check the appropriate box in Part 1 and provide your plate number so
Custom Plates Unit staff can verify your registration.
3. Complete Part 3 indicating the method of payment you will be using.
4. Follow the instructions in Part 4 for choosing a letter and/or number combination. You may submit up to three possible choices.
For each possible choice you must explain the meaning of your letter/number combination.
5. Mail your completed application and payment to:
DEPARTMENT OF MOTOR VEHICLES
CUSTOM PLATES UNIT
PO BOX 2775
ALBANY, NEW YORK 12220-0775
MV-400PH (4/11)
PAGE 1 OF 3
Current License Plate Number _______________________
o Uses portable oxygen o Legally blind o Limited or no use of one or both legs o Unable to walk 200 ft. without stopping
o Neuromuscular dysfunction that severely limits mobility o Class III or IV cardiac condition. (American Heart Assoc. standards)
o Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition.
o Restricted by lung disease to such an extent that forced (respiratory) expiratory volume for one second, when measured by spirometry,
is less than one liter, or the arterial oxygen tension is less than sixty mm/hg of room air at rest.
o Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability, and which
imposes unusual hardship in the use of public transportation and prevents the person from getting around without great difficulty.
EXPLAIN HOW THIS DISABILITY LIMITS FUNCTIONAL MOBILITY.
____________________________________________________________________________________________________________
o PERMANENT DISABILITY: A “severely disabled” person is any person with one or more of the PERMANENT impairments,
disabilities or conditions listed below which limit mobility.
Diagnosis:____________________________________________________ Please check the conditions that apply:
INFORMATION ABOUT PERSON WITH DISABILITY AND VEHICLE TO BE REGISTERED —
(Please print, and sign by the arrow.)
Last Name
See Note on Page 3
See Note on Page 3
Address: No. and Street
Apt. No.
Date of Birth
/ /
Please check here if you already
have plates for the disabled
First
City
M.I.
State
Daytime Phone (include area code)
( )
Current Plate No. Expiration Date
/ /
Zip Code
(Signature of Person with Disability or Signature of Parent or Guardian) — If signed by a parent or guardian,
please state your relationship to the person with the disability after your signature.
Check the box(es) that describe the disability, and fill in the diagnosis:
MD/DO/DPM/NP/PA Name
Professional License No.
MD/DO/DPM/NP/PA Address
Telephone No.
( )
(Date)
(Date)
ç
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(MD/DO/DPM/NP/PA Signature)
PART 1
MEDICAL CERTIFICATION—This section must be completed only by a Medical Doctor (MD), Doctor of Osteopathy (DO),
Doctor of Podiatric Medicine (DPM), Nurse Practitioner (NP), or Physician Assistant (PA).
PART 2
o
Page 1/3
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