Form 2769 (Revised 08-2024), Application for Disabled Person Placard Instructions
This form contains 61 fields organized into 16 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Additional Placard Reason (More Than One Placard) | ||
| Additional Placard Reason | Text |
Provide a brief explanation stating why an additional disabled person placard is needed (describe the medical, accessibility, or situational reason for requesting more than one placard).
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| Applicant Certification (Select All That Apply) | ||
| A disabled person | Checkbox |
Check this box if you are the disabled person for whom the placard is being requested.
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| A disabled veteran | Checkbox |
Check this box if you are a disabled veteran applying for the placard.
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| The parent or guardian of a disabled person | Checkbox |
Check this box if you are the parent or legal guardian of the disabled person for whom the placard is requested.
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| A representative of an agency that transports disabled persons | Checkbox |
Check this box if you are acting as a representative of an agency that transports disabled persons and are applying on the agency's behalf.
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| 75 years old or older (exempt from physician's statement at renewal) | Checkbox |
Check this box if you are 75 years old or older and therefore not required to submit a physician's statement at the time of renewal.
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| Applicant Contact/Signature Date | ||
| Telephone Number | Text |
Enter the applicant's daytime telephone number including area code and any extension if applicable.
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| Applicant Signature Date | Date |
Enter the date the applicant signed the form.
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| Applicant Information | ||
| Legal Name of Disabled Person | Text |
Enter the disabled person's legal name (Last, First, Middle) or business name exactly as it should appear.
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| Driver License Number or FEIN | Text |
Enter the applicant's driver license number or federal employer identification number (FEIN).
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| Date of Birth | Date |
Enter the applicant's date of birth.
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| Gender | Text |
Enter the applicant's gender.
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| Street Address | Text |
Enter the applicant's street address including house number and apartment or unit if applicable.
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| City | Text |
Enter the city for the applicant's street address.
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| State | Text |
Enter the U.S. state for the applicant's address.
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| Zip Code | Text |
Enter the postal ZIP code for the applicant's address.
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| Current Disabled Plate/Placard Number | ||
| Current disabled plate/placard number | Text |
Enter the exact license plate or placard number currently issued to the disabled person, including any letters, numbers, or punctuation as shown on the plate/placard.
|
| Disabled License Plates Status | ||
| Currently have disabled license plate(s) - Yes | Checkbox |
Check this box if you currently possess one or more disabled license plates or placards.
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| Currently have disabled license plate(s) - No | Checkbox |
Check this box if you do not currently possess any disabled license plates or placards.
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| General | ||
| Reset | Button | |
| Button | ||
| Mail-To (If Different Than Above) | ||
| Mail-To Name | Text |
Enter the full name of the person or business who should receive mail if it is different from the applicant.
|
| Mail-To Telephone Number | Text |
Enter the primary telephone number for the mail-to contact, including area code and extension if applicable.
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| Mail-To Street Address | Text |
Enter the street mailing address for the mail-to contact, including street number, street name and apartment or suite number if applicable.
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| Mail-To City | Text |
Enter the city for the mail-to address.
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| Mail-To State | Text |
Enter the state for the mail-to address (usually the two-letter state abbreviation).
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| Mail-To Zip Code | Text |
Enter the ZIP Code for the mail-to address (5-digit ZIP or ZIP+4).
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| Notary Information | ||
| Notary — Day | Text |
Enter the day of the month on which the notary subscribed and sworn. Fill only if 'Replacement - $4', 'Permanent Placard (No Fee) - Replacement' is selected (any).
Depends on:
Replacement - $4, Permanent Placard (No Fee) - Replacement
|
| Notary — Month | Text |
Enter the month in which the notary subscribed and sworn (e.g., January). Fill only if 'Replacement - $4', 'Permanent Placard (No Fee) - Replacement' is selected (any).
Depends on:
Replacement - $4, Permanent Placard (No Fee) - Replacement
|
| Notary — Year | Text |
Enter the year in which the notary subscribed and sworn. Fill only if 'Replacement - $4', 'Permanent Placard (No Fee) - Replacement' is selected (any).
Depends on:
Replacement - $4, Permanent Placard (No Fee) - Replacement
|
| Notary — State | Text |
Enter the U.S. state or jurisdiction where the notarization occurred. Fill only if 'Replacement - $4', 'Permanent Placard (No Fee) - Replacement' is selected (any).
Depends on:
Replacement - $4, Permanent Placard (No Fee) - Replacement
|
| Notary — County or City | Text |
Enter the county (or 'City of St. Louis') where the notarization took place. Fill only if 'Replacement - $4', 'Permanent Placard (No Fee) - Replacement' is selected (any).
Depends on:
Replacement - $4, Permanent Placard (No Fee) - Replacement
|
| Notary — Commission Expiration | Date |
Enter the notary's commission expiration date. Fill only if 'Replacement - $4', 'Permanent Placard (No Fee) - Replacement' is selected (any).
Depends on:
Replacement - $4, Permanent Placard (No Fee) - Replacement
|
| Notary Public Name (Typed or Printed) | Text |
Enter the notary public's full name typed or printed as it should appear on record. Fill only if 'Replacement - $4', 'Permanent Placard (No Fee) - Replacement' is selected (any).
Depends on:
Replacement - $4, Permanent Placard (No Fee) - Replacement
|
| Number of Disabled Placards Requested | ||
| Number of disabled placards currently owned | Text |
Enter the total number of disabled person placards you currently have in your possession.
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| Office Use Only | ||
| Previous Placard Number | Text |
Enter the previously assigned disabled placard number that was on record for the applicant.
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| Previous Placard Expiration Date | Date |
Enter the expiration date for the previous placard.
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| Date of Physician's Statement | Date |
Enter the date the physician's statement supporting the application was issued.
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| New Placard Number | Text |
Enter the newly assigned disabled placard number issued to the applicant.
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| New Placard Expiration Date | Date |
Enter the expiration date for the new placard.
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| Approved By | Text |
Enter the name or identifier of the office staff member who approved the placard issuance.
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| Fee Collected | Number |
Enter the fee amount collected for the placard.
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| Signature | Checkbox |
Check this box when office staff have obtained and recorded the applicant's required signature for the application.
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| Fee | Checkbox |
Check this box when the required fee for the application or replacement has been collected and processed by the office.
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| Good Cause for Additional Placard | Checkbox |
Check this box when office staff have determined and documented that there is good cause to issue an additional placard.
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| Notary (Replacement Only) | Checkbox |
Check this box when notary services have been completed for a replacement placard and the notarization has been recorded.
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| Permanent Placard Request Type (No Fee) | ||
| Permanent Placard (No Fee) - New | Checkbox |
Check this box if you are requesting a new permanent disabled person placard at no fee for the first time.
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| Permanent Placard (No Fee) - Renewal | Checkbox |
Check this box if you are requesting a renewal of an existing permanent disabled person placard at no fee.
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| Permanent Placard (No Fee) - Replacement | Checkbox |
Check this box if you are requesting a replacement for a previously issued permanent disabled person placard at no fee.
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| Record/Change Request Type | ||
| Record Change Only | Checkbox |
Check this box when you only need an internal record update (no name or address change on the placard or record).
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| Name Change | Checkbox |
Check this box when you need to change the name on the disabled placard record or placard.
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| Address Change | Checkbox |
Check this box when you need to update the address on the disabled placard record or placard.
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| Replacement Placard Number (Lost/Stolen/Mutilated/Destroyed) | ||
| Lost/Stolen/Mutilated/Destroyed Placard Number | Text |
Enter the disabled person placard number that was lost, stolen, mutilated, or destroyed as recorded on your signed receipt. Fill only if 'Lost', 'Stolen', 'Mutilated', 'Destroyed' is selected (any).
Depends on:
Lost, Stolen, Mutilated, Destroyed
|
| Replacement Placard Reason | ||
| Lost | Checkbox |
Check this box if your disabled person placard was lost and you are requesting a replacement.
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| Stolen | Checkbox |
Check this box if your disabled person placard was stolen and you are requesting a replacement.
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| Mutilated | Checkbox |
Check this box if your disabled person placard is mutilated (severely damaged) and you are requesting a replacement.
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| Destroyed | Checkbox |
Check this box if your disabled person placard was destroyed and you are requesting a replacement.
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| Never Received (Replace at no fee) | Checkbox |
Check this box if you never received the disabled person placard and are requesting a replacement at no fee.
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| Temporary Placard Request Type | ||
| New - $2 | Checkbox |
Check this box when requesting a new temporary disabled person placard and paying the $2 fee.
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| Renewal - $2 | Checkbox |
Check this box when renewing an existing temporary disabled person placard and paying the $2 renewal fee.
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| Replacement - $4 | Checkbox |
Check this box when requesting a replacement temporary disabled person placard and paying the $4 replacement fee.
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