Montana county and state authorities reserve the right to reject any form that has been altered.
MV5 (12/15) - Page 1 of 2 This form is available in alternate formats for people with disabilities.
Disability
Permit/License
Plate Application
** See Page 2 for Instructions &
Special License Plate Information **
MVD Use Only
Expiration Date:
Permit #:
[email protected] P.O. Box 201430 Helena MT 59620-1430 Phone (406) 444-3933 Fax (406) 444-3816
CHECK ONE: Applying as an individual fill out Section A only.
Applying as an organization fill out Section B only.
A
Applicant's Legal Name (first, middle, last) - please print
Driver License/ID Card/Tribal ID Number (If applicant has one)
Applicant’s Residential Address
City
State
Applicant’s Mailing Address
City
State
Do you need the special parking permit mailed to a temporary address: Yes No
If yes, temporary address:
City
State
Daytime Phone Number
Date of Birth
You are eligible for one special parking permit and one set of
license plates for each noncommercial motor vehicle you own.
If you do not own a motor vehicle, you can only receive one
special parking permit.
Number of Permits: __
The applicant certifies that: I understand that by submitting
this form I have read pages 1 and 2 of this form and agree to
comply with all the requirements for the permit or license plate
and I am authorizing the State of Montana to update my
address and customer record.
Medical Certification for an Individual: This part must be completed by a licensed
Physician, Physician's Assistant, Chiropractor, or Advanced Practice Registered Nurse.
I certify that, based on the criteria listed on page 2, the applicant is qualified for (check one):
3 year special parking permit for a permanent disability and disability vehicle plates
6 month special parking permit for a temporary disability
____ month extended special parking permit for a temporary disability (maximum 24 months)
Printed Name: Physician/PA/Chiropractor/Advanced Practice RN Type of Physician Professional License Number
Address: Physician/PA/Chiropractor/Advanced Practice RN City State and Zip Code
Signature: Physician/PA/Chiropractor/Advanced Practice RN Date Daytime Phone Number
B
The Motor Vehicle Division may issue special parking permits to an agency or business that provides transportation for
people with disabilities. The permits must be used only to load and unload people with disabilities.
Name of Organization
FEIN or Corporate ID
Mailing Address
City
State
Type of Organization (check one): Skilled Nursing Facility Nursing Home Intermediate Care Facility
Other, explain: We are applying for permit(s).
I certify that I represent an agency, business, or long-term care facility providing transportation for people with disabilities (MCA
49-4-301) and I have full authority to sign for this agency, business, or facility (MCA 49-4-302).
X
Signature Position Title
Printed Name Date Daytime Phone
Montana county and state authorities reserve the right to reject any form that has been altered.
MV5 (12/15) - Page 2 of 2 This form is available in alternate formats for people with disabilities.
MV5 Form Instructions
There is no fee for a parking permit.
Incomplete applications delay processing, please double-check before mailing.
If you have lost your unexpired placard please call the number listed on the front of this form for a
replacement.
Individuals must complete Sections A when requesting a special parking permit or plates. If you live in
in a care facility and need a permit for yourself, only complete Section A. A licensed physician, physician's
assistant, chiropractor, or advanced practice registered nurse must complete the "Medical Certification for
Individual".
Organizations only need to complete Section B.
To submit your signed and completed application:
• Email: MTDriverHistory@mt.gov
• Fax: (406)444-3816
• Mail: Motor Vehicle Division PO Box 201430 Helena, MT 59620-1430
INFORMATION FOR MEDICAL PROVIDERS
The applicant must meet one or more of the following criteria (MCA 37-8-202):
• cannot walk 200 feet without stopping to rest;
• is severely limited in ability to walk because of an arthritic, neurological, or orthopedic condition;
• is so severely disabled that the person cannot walk without the use of or assistance from a brace, cane, another person,
prosthetic device, wheelchair, or other assistive device;
• uses portable oxygen;
• is restricted by lung disease to the extent that forced expiratory respiratory volume, when measured by spirometry, is
less than 1 liter per second or the arterial oxygen tension is less than 60 mm/hg on room air at rest;
• has impairment because of cardiovascular disease or a cardiac condition to the extent that the person's functional
limitations are classified as class III or IV under standards accepted by the American Heart Association;
• has a disability resulting from an acute sensitivity to automobile emissions or from another disease or physical condition
that limits or impairs the person's mobility and that is documented by the licensed physician, licensed physician's
assistant, the licensed chiropractor, or the licensed advanced practice registered nurse as being comparable in severity
to the other conditions listed in this subsection.
The period of time a special parking permit is issued depends on whether the disability is permanent or temporary.
• A person who has a permanent disability will be issued a three year special parking permit.
• A person whose condition is expected to improve within six months will be issued a six month special parking permit.
• A person whose condition is expected to improve between six months and two years will be issued an extended special
parking permit.
INFORMATION FOR SPECIAL PARKING PERMIT HOLDERS
• You cannot transfer a special parking permit to another person. It is unlawful for you to loan this permit to any person
even i that person is disabled.
• You must prominently display the special parking permit in the windshield of the vehicle when using the special parking
permit.
• Any fraudulent or other misuse of the permit may result in the cancellation of the special parking permit or plate.
• The permit must be surrendered to the Motor Vehicle Division when you are no longer disabled or is deceased.
• Permits are valid until the last day of the month and year on the permit. You must submit a new application before the
expiration date to renew permit.
• Permanent permits issued prior to October 1993 do not require renewal.
INFORMATION ABOUT DISABILITY VEHICLE PLATES
• If you are eligible for a special parking permit and are a registered owner of a vehicle, you may apply and pay for
disabled plates with a design with a representation of a wheelchair as the symbol of a person with disability.
• You may go to your County office to receive disability vehicle plates. If you have an unexpired 3 year special parking
permit you may present this to the County to show that you are eligible for disability vehicle plates.
• If the vehicle is permanently registered, you must attach documentation of continued eligibility to use the license plate
to the vehicle’s registration.