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Form Properties
| Fact Name | Fact Details |
|---|---|
| Purpose of Form | This form is used to certify the eligibility of individuals with disabilities for special license plates or certificates in Arkansas. |
| Governing Law | The form is governed by Ark. Code Ann. §27-15-307(7), which outlines the requirements for issuing special license plates and certificates for persons with disabilities. |
| Part 1 Completion | Part 1 must be completed by a licensed physician certifying the disability of an individual, unless the applicant is an organization. |
| Part 2 Completion | Organizations that provide transportation for persons with disabilities must complete Part 2 of the form. |
| Disability Types | The form includes specific criteria (A through L) that define various disabilities, including mobility impairments and chronic health conditions. |
| Temporary Certificates | Temporary certificates are valid for three months from the last day of the month in which they are issued. |
| Permanently Disabled Certificates | Certificates for permanently disabled individuals expire four years from the last day of the month in which they are issued, without the need for re-certification. |
| False Information Penalty | Providing false information to obtain a special plate or certificate is considered a Class A misdemeanor. |
| Parking Privileges | Special license plates or certificates allow parking in designated spaces only when transporting the individual for whom the plate or certificate was issued. |
Key takeaways
Filling out the Arkansas 10 336 form is an important step for individuals with disabilities seeking special license plates or certificates. Here are key takeaways to keep in mind:
- Complete the Correct Part: If you are a licensed physician, fill out Part 1. Organizations providing transportation for individuals with disabilities should complete Part 2.
- Provide Accurate Information: Ensure all personal details, including the name and address of both the physician and the person with a disability, are correct.
- Certification Requirement: Physicians must certify that the individual is disabled, either permanently or temporarily, by checking the appropriate boxes that describe their condition.
- Temporary Placard Information: If applying for a temporary placard, include the individual's Social Security Number or driver’s license number for identification purposes.
- Usage of Special Plates: Special license plates or certificates are only valid when the vehicle is used to transport the person for whom they were issued.
- Display Requirements: Special certificates must be displayed on the inside rearview mirror or dashboard if the vehicle lacks a rearview mirror.
- Consequences for Misuse: Providing false information or abusing the privileges granted by a special plate or certificate can result in serious legal consequences, including fines and misdemeanor charges.
- Expiration and Renewal: Special certificates for permanently disabled individuals expire four years after issuance, while temporary certificates expire after three months. No re-certification is needed for renewal of permanent certificates.
Understanding these points can help ensure a smoother application process and compliance with the law. Act promptly to secure the benefits you or your organization may be entitled to.
Detailed Steps for Using Arkansas 10 336
Filling out the Arkansas 10 336 form is a crucial step for individuals or organizations seeking a special license plate or certificate for persons with disabilities. It is important to ensure that all information is accurate and complete to avoid any delays in processing. Below are the steps to guide you through filling out the form.
- Obtain the Arkansas 10 336 form from the appropriate source, such as the Arkansas Department of Finance and Administration.
- Identify whether you are filling out Part 1 (for individuals) or Part 2 (for organizations).
- If completing Part 1, provide the following information:
- Name of Physician
- Physician’s Address, City, State, and Zip Code
- Name of Person with Disability
- Person’s Address, City, State, and Zip Code
- If applying for a Temporary Placard, include the Social Security Number, Driver’s License Number, or State Assigned Identification Number
- Certify the individual’s disability by indicating whether it is permanent or temporary. Circle the appropriate option.
- Check the box or boxes (A through L) that best describe the individual’s condition(s). If none apply, write the permanent medical condition impacting mobility.
- Sign and date the form where indicated.
- If completing Part 2 for an organization, provide the following information:
- Name of Organization
- Organization’s Address, City, State, and Zip Code
- Federal Employer Identification Number
- Certify that the organization owns or leases vehicles for transporting persons with disabilities by checking the box provided.
- Have an authorized official sign and date the form.
After completing the form, ensure that all required signatures are in place. The next step will be to submit the form to the appropriate department for processing. Keep a copy for your records, as it may be needed for future reference or follow-up.
Common mistakes
Filling out the Arkansas 10 336 form can be a straightforward process, but many people make common mistakes that can delay their application or lead to complications. One frequent error occurs when applicants fail to provide the necessary identification numbers. The form requires the photo ID number, driver’s license number, or state-assigned identification number of the person with a disability. Without this information, the department cannot properly process the application or maintain accurate statistical records.
Another common mistake is neglecting to circle the appropriate category indicating whether the disability is permanent or temporary. This section is crucial because it determines the type of special license plate or certificate issued. If an applicant mistakenly selects the wrong option, it could result in receiving a temporary permit when a permanent one is needed, or vice versa. This oversight can lead to confusion and additional paperwork.
Additionally, some applicants overlook the requirement to check the specific boxes that describe the individual’s disability. The form lists several conditions, and it’s essential to mark all that apply. Failing to do so can result in an incomplete application. In some cases, applicants might even leave the section blank, which can further delay the approval process.
Lastly, many individuals forget to obtain the required signature from the licensed physician or authorized organization official. The signature serves as a certification of the disability and is a vital component of the application. If the form is submitted without this signature, it will likely be rejected, necessitating a resubmission and causing unnecessary delays in obtaining the special license plate or certificate.
Arkansas 10 336 Sample
STATE OF ARKANSAS
LICENSED PHYSICIAN’S OR ORGANIZATION’S CERTIFICATION FOR ISSUANCE
OF A SPECIAL LICENSE PLATE OR CERTIFICATE FOR A PERSON WITH A DISABILITY
If a licensed physician certifying an individual, complete Part 1. If an organization providing transportation for persons with a disability with conditions in A through L below, complete Part 2.
Notice to Applicant: The department is required to enter into the permanent record disability types in a manner that will allow retrieval of such information for statistical use. The photo ID number or driver’s license number of the person with a disability is necessary to identify and retrieve these statistics.
PART 1: TO BE COMPLETED BY A LICENSED PHYSICIAN AND APPLICANT (UNLESS APPLICANT IS AN ORGANIZATION)
Name of Physician:
Address:
City State Zip:
Name of Person with Disability:
Address:
City State Zip:
If Temporary Placard need Social Security Number, Driver’s
License Number or State Assigned Identification Number:
I hereby certify that the individual listed above is or has been a patient under my care and is disabled either permanently or temporarily as indicated below.
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CIRCLE ONE: |
PERMANENTLY |
TEMPORARILY |
Check the appropriate box or boxes A through L, which defines the patient’s condition(s). |
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(A) Cannot walk one hundred (100) feet without stopping to rest; |
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(B) |
Cannot walk without the use of or assistance from a brace, cane, crutch, another person, prosthetic device, wheelchair, or |
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other assistive device; |
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(C) |
Is restricted by lung disease to such an extent that the person’s forced respiratory expiratory volume for one (1) second, |
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when measured by spirometry, is less than one (1) liter, or the arterial oxygen tension is less than sixty (60) mm/hg on room |
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air at rest; |
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(D) Uses portable oxygen; |
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(E) |
Has a cardiac condition to the extent that the person’s functional limitations are classified in severity as Class III or Class IV |
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according to standards set by the American Heart Association; |
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(F) |
Spinal cord injury; |
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(G) |
Genetic ambulatory disorder; |
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(H) |
An amputation; |
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(I) |
Spina bifida; |
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(J) |
Multiple Sclerosis; |
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(K) |
Chronic heart disease; |
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(L) |
Other:______________________________________________________________________________________________ |
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If none of the conditions in A through L above applies, list the permanent medical condition that substantially impacts the person’s mobility.
Signature of Physician:
Date
PART 2: TO BE COMPLETED IF APPLICANT IS AN ORGANIZATION
Name of Organization:
Address:
City State Zip:
Federal Employer Identification Number:
(M) This is to certify that the organization above owns or leases vehicles used primarily for transporting persons with disabilities as defined in items (A) through (L) in Part 1.
Signature of Authorized Organization Official:
Date
IMPORTANT NOTICE ON BACK
10/07 |
APPLICANTS AND PERSONS DRIVING FOR APPLICANTS WHO REQUEST
A SPECIAL LICENSE PLATE OR SPECIAL CERTIFICATE FOR PERSONS WITH A DISABILITY
The following requirements are provided in accordance with Ark. Code Ann.
•The privilege to park in spaces reserved for persons with disabilities shall be available only when the vehicle is being used to transport the person for whom the special plate or certificate was issued.
•Special certificates must be displayed on the inside rearview mirror, or on the dashboard, if the vehicle is of a type that does not have an inside rearview mirror.
•Any individual who provides false information to obtain a special plate or certificate, or assists an unqualified person in acquiring a special license plate or special certificate shall be deemed guilty of a Class A misdemeanor.
•Any person who abuses the privileges granted by a special license plate or certificate shall be deemed guilty of a Class A misdemeanor.
•Any unauthorized vehicle found to be parked in an area designated for the exclusive use of a person with a disability shall be subject to impoundment by the appropriate law enforcement agency. In addition to impoundment, the owner of the vehicle shall upon conviction be subject to fine of not less than one hundred dollars ($100) nor more than five hundred dollars ($500) for the first offense, nor less than two hundred fifty dollars ($250) nor more one thousand dollars ($1000) for the second and subsequent offense, plus applicable towing, impoundment, and related fees as well as court costs. Upon the second or subsequent conviction, the court shall suspend the driver’s license for up to six (6) months. The driver may apply to the Office of Driver Services of the Arkansas Department of Finance and Administration for a restricted license during the period of suspension.
•If a person to whom a special certificate or license plate has been issued moves to another state, the person shall surrender the special certificate or plate to the nearest Revenue Office.
•If a person to whom a special certificate or license plate has been issued dies, the special certificate or license plate shall be returned to the Revenue Office within thirty (30) days after the death of the person to whom the special certificate or plate was issued.
•The special certificate issued for the permanently disabled shall expire four (4) years from the last day of the month in which it was issued. The applicant shall not be required to obtain
•The special temporary certificate shall expire three (3) months from the last day of the month in which it was issued.