Article Structure
The DSMV 16 form serves as an essential application for individuals seeking walking disability privileges in New Hampshire. This application allows for different types of accommodations, including hanging placards, walking disability plates, and custom vanity plates. Applicants must confirm their eligibility by providing personal details such as their name, address, and the specifics of their walking disability, which must be verified by a licensed physician. The form outlines the criteria for both permanent and temporary walking disabilities, following guidelines set forth in state law. Requirements for submission include the completion of the necessary sections by both the applicant and a medical professional, ensuring that disabilities meet defined standards. Furthermore, organizations that support individuals with walking disabilities may also apply on behalf of their clients. Fees for the plates and placards are explicitly detailed, along with instructions for submission. Understanding the components of the DSMV 16 form is crucial for navigating the process of obtaining necessary mobility assistance effectively.
Dsmv 16 Example
STATE OF NEW HAMPSHIRE
DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES JAMES H. HAYES SAFETY BUILDING 10 HAZEN DRIVE, CONCORD, NH 03305
APPLICATION
FOR
WALKING DISABILITY
PRIVILEGES
Check Items Required:
___ Hanging Placard
___ Walking Disability Plates
___ Walking Disability Vanity Plates
THIS APPLICATION IS FILED PURSUANT TO THE APPLICABLE PROVISIONS OF NH RSA 261:88
(Refer to Eligibility Requirements On Reverse Side)
LAST NAMEFIRST NAMEMIDDLE NAME
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STREET ADDRESS OR RFD AND BOX NO. |
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I, the undersigned applicant, certify under penalty of unsworn falsification pursuant to RSA 641:3, that I am a resident of this State qualified for Walking Disability Privileges or that I provide primary transportation for the named applicant, as a member of that relative’s household.
APPLICANT’S SIGNATURE: DATE:
THIS CERTIFICATION MUST BE COMPLETED BY A MEDICAL DOCTOR
I certify, under the penalty of perjury, that the person whose name appears is under my treatment and care and in my professional opinion has a walking disability as defined under RSA 259:124.
The condition is: |
PERMANENT TEMPORARY: |
for a period of Months |
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(Not to exceed six months) |
Brief Description of walking disability: ___________________________________________________________________________
PHYSICIAN’S SIGNATURE |
M.D. DATE |
PHYSICIAN’S NAME (PRINT LEGIBLY) |
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ORGANIZATIONS
COMPLETE
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l/We certify, under penalty of unsworn falsification pursuant to RSA 641:3, that the business identified herein is owned by an organization in the private or public sector that is primarily engaged in a business in this state involving care, treatment, rehabilitation or transportation of persons with walking disabilities.
Business Name:
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Signature of ApplicantTelephone#
BUSINESS OWNER
LAST NAME |
FIRST NAME |
MIDDLE NAME |
VEHICLE OWNER
FULL ADDRESS
STREET ADDRESS OR RFD AND BOX NO.
CITY OR TOWN |
COUNTY |
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VEHICLE OWNER’S DATE OF BIRTH
MONTH DAY YEAR
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PLATE NO.
PLATE TYPE MFG. YR.
MAKE MODEL
WALKING DISABILITY PLATES |
WALKING DISABILITY VANITY PLATES WALKING DISABILITY PLACARD NO. |
ISSUED:
DSMV16 (Rev.02/00)
GENERAL INSTRUCTIONS:
WALKING DISABILITY PLATES, VANITY PLATES, AND REMOVABLE HANGING PLACARDS
WALKING DISABILITY PLATES: If you have a permanent disability that qualifies you for Walking Disability Privileges, you may apply for walking disability plates containing the international accessibility symbol and a distinguishing number. An exchange of the plates you may currently hold may be made at the central office in Concord. A fee of $5.00 is required.
WALKING DISABILITY VANITY PLATES: If you have a permanent disability that qualifies you for Walking Disability Privileges, you may apply for vanity plates containing the international accessibility symbol and such letter and numbers as may be available for such plates. The fee shall be $30.00 in addition to the normal registration fee for such vehicle.
HANGING PLACARDS: An applicant who qualifies for walking disability plates may apply for a removable windshield placard containing the international accessibility symbol. Those with permanent disabilities shall be issued a blue placard with white lettering. The placard shall be removed from the
HANGING PLACARDS - (TEMPORARY): An applicant with a temporary walking disability is not entitled to walking disability plates but may be issued a removable windshield placard containing the international accessibility symbol which shall be a red placard with white lettering and shall not be valid for more than a six (6) month period.
DEPENDENT TRANSPORTATION: Walking disability plates, or a permanent or temporary hanging placard may be issued for use on a vehicle owned by a relative of a person with a walking disability, if the vehicle owner is a resident of this state, a member of that relative’s household and the disabled person is dependent on the vehicle owner as his/her primary means of transportation.
QUALIFYING ORGANIZATION: Walking disability plates, vanity plates or hanging placards may be issued for use on motor vehicles owned by an organization the private or public sector that is primarily engaged in a business in this state involving care, treatment, rehabilitation, or transportation of persons with walking disabilities.
DEFINITION OF WALKING DISABILITY: ‘‘Walking Disability”, as used in RSA 261:88 (c) means a disability which limits or impairs a person’s ability to walk, as determined by a licensed physician, to such an extend that such person:
I.Cannot walk without the use of, or assistance from, brace, cane, crutch, another person, prosthetic device,
wheelchair, or other assistance device; or
II.Is restricted by lung cancer to such an extent that the person’s forced (respiratory) expiratory volume for one second, when measured by spirometry, is less than one (1) liter, or the arterial oxygen tension is less than 60
mm/hg on room air at rest; or III. Uses portable oxygen; or
IV. Has a cardiac condition to the extent that the person’s functional limitations are classified in severity as class 3 or class 4 according to the standards set by the American Heart Association; or
V.Is severely limited in the ability to walk due to an arthritic, neurological, orthopedic, or other medically disabled condition.
PARKING PRIVILEGES FOR PERSONS WITH WALKING DISABILITY: (RSA 265:74) Any motor vehicle carrying the special plates or hanging windshield placard issued to a person with a walking disability under RSA 261:88, or a similar license plate or card issued by another state or country displaying the international accessibility symbol shall be allowed free parking in any city of town, including any state or municipal parking facility where a fee is charged. Each city or town shall have the discretion to set the time periods using guidelines which shall be provided by the governor’s commission on disability. The free parking shall only be allowed if the person who qualifies for the special plates or hanging placard is being transported in the vehicle to or from the parking place.
SPECIAL NOTE TO APPLICANT: If this is NOT the registration month of the named registered owner, and you wish to obtain Walking Disability Plates, submit a photocopy of your present registration certificate and a check in the amount of $5.00 (payable to State of N.H. - M.V.) DO NOT MAIL CASH.
MAIL COMPLETED APPLICATION AND ANY REQUIRED FEEDS TO:
ATTN: WALKING DISABILITY DESK
DEPARTMENT OF SAFETY
DIVISION OF MOTOR VEHICLES JAMES H. HAYES SAFETY BUILDING 10 HAZEN DRIVE, CONCORD, NH 03305
Form Characteristics
| Fact Name | Description |
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| Governing Law | This form is governed by New Hampshire Revised Statutes Annotated (NH RSA) 261:88. |
| Application Purpose | The DSMV 16 form serves as an application for walking disability privileges, allowing access to special parking and vehicle registration options. |
| Eligibility Requirements | Applicants must meet specific criteria outlined in RSA 259:124 to be considered for walking disability privileges. |
| Types of Privileges | Privileges include hanging placards, walking disability plates, and walking disability vanity plates. |
| Medical Certification | A licensed physician must certify the applicant's disability, using the designated section of the form. |
| Temporary vs Permanent | Both temporary and permanent walking disabilities can be recognized, impacting the type of placard or plate issued. |
| Cost | A fee of $5.00 is required for walking disability plates, while vanity plates incur an additional fee of $30.00. |
| Parking Privileges | Vehicles with special plates or placards are allowed free parking in designated areas, provided the qualifying individual is present. |
Guidelines on Utilizing Dsmv 16
Completing the Dsmv 16 form is an essential step for individuals seeking walking disability privileges in New Hampshire. By filling out the application accurately, applicants can ensure their needs are effectively addressed. Once the form is submitted along with any required documents and fees, the processing typically follows a set timeline, allowing for the issuance of the necessary plates or placards.
- Begin by checking the appropriate items required for your application. Choose between the Hanging Placard, Walking Disability Plates, or Walking Disability Vanity Plates.
- Fill in your last name, first name, and middle name in the designated fields.
- Provide your complete street address, including city or town, county, state, and ZIP code.
- Although optional, include your telephone number for any follow-ups.
- Enter your date of birth in the specified format (month, day, year).
- Input the vehicle plate number and type, along with the vehicle's make, model, and manufacturing year.
- Sign the form as the applicant, certifying your residency and eligibility for walking disability privileges. Include the date of your signature.
- Obtain the certification from a medical doctor. The physician should provide their signature, date, and printed name, confirming your walking disability.
- In the section for the physician, indicate whether the disability is permanent or temporary. If temporary, specify the duration in months and give a brief description of the walking disability.
- For organizational applications, include the business name and complete address. The authorized applicant of the organization should sign and provide their phone number.
- Ensure all information is clear and legible to avoid any processing delays.
- Prepare a check for any applicable fees: $5.00 for regular plates and $30.00 for vanity plates, made out to the State of N.H. - M.V.
- Finally, mail the completed application along with any required documents and fees to:
- ATTN: WALKING DISABILITY DESK
- DEPARTMENT OF SAFETY
- DIVISION OF MOTOR VEHICLES
- JAMES H. HAYES SAFETY BUILDING
- 10 HAZEN DRIVE, CONCORD, NH 03305
What You Should Know About This Form
What is the DSMV 16 form used for?
The DSMV 16 form is an application for Walking Disability Privileges in New Hampshire. This form allows individuals with walking disabilities to request special accommodations such as walking disability plates, vanity plates, or hanging placards to help them access parking and other facilities more easily.
Who is eligible to apply for Walking Disability Privileges?
Individuals who meet specific requirements defined in RSA 261:88 can apply. Generally, this includes those with permanent walking disabilities that limit their ability to walk without assistance from devices or people. A licensed physician must certify the disability on the form.
How do I complete the application process?
To complete the application, fill out the form with your personal information, including your name, address, and details about your disability. You must also have a physician complete the certification section. After filling out the form, you can submit it along with any required fees to the address provided on the form.
What types of plates or placards can I apply for?
You can apply for several options: walking disability plates, walking disability vanity plates, and removable hanging placards. The walking disability plates will display the international accessibility symbol and a distinguishing number. Vanity plates can also feature custom letters and numbers, while hanging placards can be either blue for permanent disabilities or red for temporary ones.
Is there a cost associated with the application?
Yes, there are fees involved. For walking disability plates, there is a $5.00 fee. Vanity plates require an additional fee of $30.00, on top of the regular vehicle registration fee. When applying for hanging placards, check for specific fees associated with those as well.
Can a relative apply for disability privileges on behalf of someone else?
Yes, a relative can apply for walking disability privileges on behalf of an individual with a walking disability. The relative must also be a resident of New Hampshire and serve as the primary means of transportation for the disabled individual.
What parking privileges do I have with these special plates or placards?
Vehicles displaying walking disability plates or hanging placards are allowed free parking in cities and towns with paid parking facilities, provided the individual with the disability is being transported in the vehicle. It's important to note that the specific terms of free parking may vary depending on local regulations.
Common mistakes
Completing the DSMV 16 form can be a straightforward process, yet several common errors can complicate the application. One significant mistake is failing to provide complete and accurate contact information. This includes missing details such as the applicant's telephone number, which, while optional, can expedite communication if issues arise. Incomplete addresses can lead to delays in processing the application.
Another frequent error is neglecting to check the appropriate items required for the application. Applicants often overlook designating whether they want a hanging placard, walking disability plates, or vanity plates. Each option has different eligibility and fee requirements, so selecting the correct items is essential to avoid unnecessary rejections.
Additionally, many applicants misunderstand the eligibility criteria established by New Hampshire law. Some submit an application without having the necessary certification from a licensed physician. This step is crucial, as the certification is a requirement that confirms the applicant's walking disability. Without it, the application cannot proceed.
Missing signatures is also a common issue. Each section of the DSMV 16 form requires proper signatures from the applicant and the certifying physician. If either signature is absent, the application may be considered incomplete. Ensuring all signatures are in place will facilitate a smoother review process.
Another mistake involves the classification of the walking disability. Applicants mistakenly indicate that their condition is temporary without adhering to the specific guidelines. For example, temporary disabilities can only be certified for a maximum of six months and must be clearly stated in the application. Proper classification helps the processing agency assess eligibility accurately.
Lastly, applicants sometimes fail to submit the correct fee associated with their application. The form outlines specific fees for walking disability plates and vanity plates. Submitting an incorrect amount can lead to delays or outright rejection of the application, necessitating additional efforts to rectify the mistake.
Documents used along the form
When applying for Walking Disability Privileges using the DSMV 16 form, there are several other documents that you may need to consider. Each of these forms serves a specific purpose in the process and helps ensure that applicants meet the necessary requirements. Below is a list of commonly associated documents.
- Certification of Disability: This document is needed to verify your walking disability. It must be completed and signed by a licensed physician. The certification should detail the nature of your condition and confirm that it limits your ability to walk.
- Vehicle Registration Application: In some cases, you might need to submit an application for registering the vehicle that will display the disability plates. This application provides essential information about the vehicle and its owner.
- Proof of Residency: This document proves that you are a resident of New Hampshire. It can be in the form of a utility bill, lease agreement, or another official document that displays your name and address.
- Power of Attorney: If the application is being handled by someone other than the person with the disability, a Power of Attorney document may be required. This shows that the individual assisting you has the legal authority to act on your behalf.
- Payment Receipt: Keep a record of any payments made for the application process, whether for the plates, placards, or other related fees. This receipt is essential for verifying that fees were correctly submitted.
Gathering the necessary documents will streamline your application process. Make sure to review all requirements carefully to ensure a smooth experience. It’s important to follow all guidelines to achieve the privileges you deserve without unnecessary delays.
Similar forms
DMV Form for Disabled Parking Privileges: Similar to the DSMV 16, this form is used to apply for parking privileges for individuals with disabilities. It requires medical certification of the disability and supports the issuance of a special parking placard or plate.
Application for Accessible Parking Permit: This document serves the same purpose as the DSMV 16 form. It allows eligible persons with disabilities to request a permit for accessible parking, which includes specific documentation from a healthcare provider about the individual's condition.
Request for Specialty License Plates: Individuals can apply for special license plates indicating a disability, similar to options available under the DSMV 16. This process also includes documentation of the disability from a medical professional.
Temporary Disability Parking Permit Application: Like the DSMV 16 form, this application caters to those with temporary disabilities. It provides guidelines for qualifying and obtaining a temporary permit for accessible parking.
State-Specific Disability Certification Form: This document requires individuals to provide details about their disability, akin to the DSMV 16. It ensures that the disability is verified by a healthcare provider before any related privileges are granted.
Dos and Don'ts
When filling out the DSMV 16 form, keep the following tips in mind:
- Make sure to provide your full name, including last, first, and middle names.
- Ensure that your street address, city, and zip code are complete and accurate.
- Check that all required items are marked clearly on the application.
- Obtain the necessary certification from a licensed physician regarding the walking disability.
- Sign and date the application where indicated.
Be aware of these common mistakes to avoid:
- Do not leave any sections of the application blank; this may lead to delays.
- Avoid submitting cash; always use a check for any fees.
- Do not forget to provide a brief description of the walking disability.
- Refrain from mailing incomplete applications; make sure all documentation is attached.
Misconceptions
Many people have misconceptions about the DSMV 16 form related to walking disability privileges. Below is a list of these common misunderstandings, along with clarifications to provide accurate information.
- Only permanent disabilities qualify: Some believe that only individuals with permanent disabilities can apply. However, the form allows for temporary disabilities as well, with a specific process for obtaining a temporary placard.
- Medical certification is optional: Many think that a doctor's certification is not necessary for the application. This is incorrect. A licensed medical physician must certify the walking disability to validate the application.
- Anyone can use the placard or plates: Some people assume that once they have the placard or plates, anyone can use them. In reality, the privileges are intended for the individual with the disability and must be used when they are present in the vehicle.
- There are no fees involved: A misconception exists that applying for these privileges is free. In fact, there are fees associated with obtaining disability plates and vanity plates.
- Hanging placards are permanent: It is often thought that hanging placards are issued permanently. In truth, those with temporary disabilities receive a placard that is only valid for a limited period, typically up to six months.
- Parking benefits apply everywhere: Some applicants believe that the special parking privileges apply universally. However, these privileges are only valid if the individual with the disability is being transported in the vehicle, and cities may have specific regulations regarding free parking.
It is essential to understand the facts surrounding the DSMV 16 form to ensure that individuals can access the benefits they need safely and legally.
Key takeaways
The DSMV 16 form is used in New Hampshire to apply for walking disability privileges, which can include special plates, vanity plates, and hanging placards. Here are eight key takeaways to understand the process and requirements:
- Eligibility is essential. Applicants must meet specific criteria, as outlined in RSA 261:88.
- Medical certification is required. A licensed physician must complete the certification section, confirming the applicant has a walking disability.
- Applicants may receive multiple items. You can apply for walking disability plates, hanging placards, or vanity plates simultaneously.
- Fees are applicable. There is a $5.00 fee for walking disability plates and a $30.00 fee for vanity plates on top of regular vehicle registration costs.
- Temporary options are available. Individuals with temporary walking disabilities can request a red placard, valid for no more than six months.
- Dependent transportation is allowed. Plates or placards may be issued for vehicles owned by relatives of a person with a walking disability if certain conditions are met.
- Parking privileges come with the permits. Vehicles displaying the appropriate plates or placards enjoy free parking in cities and towns that charge fees, subject to specific conditions.
- Keep the application records. Ensure all required signatures and details are accurately provided to avoid processing delays.
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