Form MV-664.1MP - Application for a Metered Parking Waiver - New York
MV-664MP No. Issued: __________________ Date Issued:_______________ MV-664 No. Issued: ____________________
F Part A
l Uses portable oxygen
l Legally blind
l Limited or no use of one or both legs
l Unable to walk 200 ft. without stopping
l Neuromuscular dysfunction that severely limits mobility
l Class III or IV cardiac condition. (American Heart Association standards)
l Severely limited in ability to walk due to an arthritic, neurological or orthopedic condition
l 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
l 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.
F Part B
Please certify that the severely disabled patient (as described in Part A) also has a severe disability
that limits one or more of the following (check all that apply):
o Fine motor control of both hands
o Ability to reach or access a parking meter due to use of a wheelchair or other ambulatory device
o Ability to reach a height of 42 inches from the ground due to lack of finger, hand, or upper extremity strength or
mobility.
APPLICATION FOR A METERED PARKING
WAIVER FOR PERSONS WITH SEVERE DISABILITIES
INFORMATION ABOUT PERSON WITH DISABILITY — (Please print, and sign by the arrow.)
Last Name
Address: No. and Street Apt. No.
Date of Birth
o Male
o Female
Driver License Number and Expiration Date: __________________________________________________________
Do you have license plates for persons with disabilities?
o No o Yes, plate number is:_____________________
Do you have a parking permit for persons with disabilities?
o No o Yes, permit number is:____________________
First
City
M.I.
State
Telephone No.
( )
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.
Instructions for completing this application are on page 2. Take the completed application to the issuing agent in the area where you
live. Please bring your New York State driver license with you when you apply for the waiver.
MV-664.1MP (4/15)
File Information (For Issuing Agent Use Only)
PAGE 1 OF 2
MEDICAL CERTIFICATION—This section must be completed only by a physician, physician assistant (PA), or doctor of
osteopathy (DO).
Physician/PA/DO Name (Print/Type)
Professional License No.
Physician/PA/DO Address (Print/Type)
Telephone No.
( )
(Date)
(Date)
ç
(Physician/PA/DO Signature)
By signing this form I certify that this severely disabled patient (as defined by NYS Vehicle and Traffic Law Section 404-a) has a
disability limiting one or more of the actions listed in Part B above. I understand that making a false statement or providing
misinformation on an application to obtain or facilitate the receipt of a metered parking waiver for people with disabilities may
result in a civil penalty ranging from $250-$1,000 and/or criminal prosecution and penalties.
The metered parking waiver is available to people who are severely disabled as defined in Vehicle and Traffic Law Section 404-a
(see Part A) AND
who also have a disability that hinders their ability to put payment into a parking meter (see Part B).
By signing this form I certify that I meet the requirements for a metered parking waiver. I understand that making a false statement
or providing misinformation on an application to obtain or facilitate the receipt of a metered parking waiver for people with
disabilities may result in a civil penalty ranging from $250-$1,000 and/or criminal prosecution and penalties.
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