OH BMV 4826 2024-2025 free printable template

2921. 13. BMV 4826 3/24 760-0616 Page 1 of 2 RESTRICTED CERTIFICATION FOR PRESCRIPTION R.C. 4503. 44 Cannot walk two hundred feet without stopping to rest. BMV OR DEPUTY USE ONLY OHIO DEPARTMENT OF PUBLIC SAFETY BUREAU OF MOTOR VEHICLES PLACARD NUMBER ISSUE DATE APPLICATION FOR REMOVABLE WINDSHIELD PLACARDS SEE REVERSE SIDE FOR INSTRUCTIONS NOTE A PRESCRIPTION FROM YOUR HEALTH CARE PROVIDER MUST BE SUBMITTED WITH THIS Instructions are on page 2. Ohio Revised Code R*C. 4503. 44 allows an...applicant to obtain one removable windshield placard. A person with a disability that limits or impairs the ability to walk is entitled to request one additional placard that may be issued at the discretion of the Registrar. Consideration will be given only if the person applies separately for an additional placard and states the reason why the additional placard is necessary additional fees apply. Please allow 10-15 business days for processing if the form is submitted by mail* INDICATE TYPE OF...PLACARD REQUESTED NOTE Placard expiration date is determined by the length of time indicated on the prescription Temporary Placard Standard Placard Permanent Placard No Expiration Duration 6 months or less 15. 00 Duration Over 6 months and up to 10 years NOTE Organizations are only eligible for a Standard Placard Renewal Standard Placard Replacement Placard Do not renew more than 90 days from expiration date Reason Additional Placard 5. 00 Temporary/Standard 15. 00 Permanent Lost Damaged Stolen...List Reason Previous Placard Number applies only to renewal or replacement You may make a non-refundable donation to Opportunities for Ohioans with Disabilities OOD by checking the box below and entering the amount you wish to donate. For more information please visit https //ood. ohio. gov/wps/portal/gov/ood/about-us/resources/donations-to-ood. I would like to donate to the Opportunities for Ohioans with Disabilities. Add this to your total fees due. TO BE COMPLETED BY APPLICANT PLEASE PRINT OR...TYPE NAME OF PERSON WITH A DISABILITY STREET ADDRESS CITY STATE DL / ID / SSN OF PERSON WITH A DISABILITY ZIP CODE TELEPHONE NUMBER SIGNATURE OF PERSON WITH A DISABILITY NEXT OF KIN OR CARE PROVIDER X COUNTY DATE SIGNED APPLICATION BY AN ORGANIZATION This is to certify that we are a private organization or corporation or any governmental board agency department division or office that as part of its business or program transports people with disabilities limited or impaired ability to walk on a...regular basis in a motor vehicle that has not been altered for the purpose of providing it with special equipment for use by people with disabilities. NAME OF AUTHORIZED AGENT / OFFICER TITLE / POSITION NAME OF ORGANIZATION FEDERAL TAX ID / CHARTER NUMBER SERVICE PROVIDED FOR PERSONS WITH DISABILITIES SIGNATURE OF AUTHORIZED AGENT / OFFICER Warning Knowingly making a false statement on this form constitutes falsification a first-degree misdemeanor punishable by criminal fines and imprisonment...and also may result in civil liability R*C.