Kansas Department Of Revenue

Division of Vehicles

Self certification of continued eligibility for disabled parking privilege

Persornal Information of Disabled Individual
Male Female

(xxxxx or xxxxx-xxxx)

I, undersigned disabled individual or guardian of a disabled individual, do hearby certify that I am considered permanently disabled or that the person that I am responsible for transporting is considered permanently disabled as per KSA 8-1,124. I further certify of perjury under the laws of theState of Kansas that the forgoing if true and correct.