Blank Arkansas 10 336 Form

1. What is the purpose of the Arkansas 10 336 form?

   The Arkansas 10 336 form serves as a certification for individuals with disabilities to obtain a special license plate or certificate. This document can be completed by a licensed physician or an organization that provides transportation for persons with disabilities. It helps identify individuals who require special parking privileges due to their mobility challenges.

2. Who is eligible to complete Part 1 of the form?

   Part 1 of the Arkansas 10 336 form must be completed by a licensed physician who is certifying an individual with a disability. The physician must have a valid relationship with the patient and be able to confirm their disability status, whether permanent or temporary.

3. What information is required in Part 1?

   In Part 1, the physician must provide their name, address, and the name and address of the person with a disability. Additionally, the physician must indicate whether the disability is permanent or temporary, and check the relevant boxes that describe the patient's condition from a provided list.

4. What conditions qualify for a special license plate or certificate?

   The form includes a list of conditions that qualify for a special license plate or certificate. These include, but are not limited to:

   • Inability to walk without assistance
   • Severe lung disease
   • Cardiac conditions classified as Class III or IV
   • Spinal cord injury
   • Amputation
   • Multiple Sclerosis
   • Chronic heart disease

   If none of the listed conditions apply, the physician can specify another permanent medical condition that substantially impacts mobility.

5. What should an organization do to complete Part 2 of the form?

   If the applicant is an organization, Part 2 must be completed. The organization must provide its name, address, and Federal Employer Identification Number. The authorized official must certify that the organization owns or leases vehicles primarily used for transporting persons with disabilities as defined in Part 1.

6. What are the consequences of providing false information on the form?

   Providing false information to obtain a special license plate or certificate is a serious offense. Individuals found guilty of this act may face a Class A misdemeanor charge. This applies to both the person providing false information and those assisting unqualified individuals in acquiring these privileges.

7. What happens if a special certificate or license plate is no longer needed?

   If a person with a special certificate or license plate moves to another state or passes away, they must return the certificate or plate to the nearest Revenue Office. This must be done within a specified time frame, typically within thirty days after the death of the individual.

8. How long is the special certificate valid?

   The special certificate issued for permanently disabled individuals is valid for four years from the last day of the month in which it was issued. For temporary certificates, the validity period is three months. Renewal does not require re-certification of the qualifying disability for permanent certificates.

Completing the Arkansas 10 336 form requires careful attention to detail. One common mistake is failing to provide the correct identification number for the person with a disability. This number, which can be a photo ID number, driver’s license number, or state-assigned identification number, is essential for the department to track disability statistics accurately. Without this information, the application may be delayed or rejected.

Another frequent error involves neglecting to specify whether the disability is permanent or temporary. The form requires the applicant to circle one option, yet some individuals overlook this step. This oversight can lead to confusion and may result in the issuance of an incorrect license plate or certificate.

Inaccurate completion of the medical condition section is also a prevalent issue. Applicants must check the appropriate boxes (A through L) that correspond to the individual’s condition. Failing to check any boxes or selecting the wrong ones can lead to significant complications in the approval process. It is vital that the conditions listed accurately reflect the individual’s health status.

Moreover, signatures are critical. The form requires the signature of the licensed physician or an authorized organization official. Some applicants forget to include this signature, which can render the application invalid. It is important to double-check that all required signatures are present before submission.

Additionally, individuals often overlook the requirement to provide an address for both the physician and the person with a disability. Missing this information can hinder the processing of the application. Ensuring that all addresses are complete and accurate is essential for timely communication from the department.

Lastly, applicants sometimes fail to read the important notices on the back of the form. These notices outline the responsibilities and potential penalties associated with the misuse of the special license plate or certificate. Ignoring this information can lead to unintentional violations of the law, resulting in fines or other legal repercussions.

When applying for a special license plate or certificate for a person with a disability in Arkansas, the Arkansas 10 336 form is essential. However, several other documents may also be required to support your application. Understanding these additional forms can streamline the process and ensure that everything is in order. Below are some common forms and documents that often accompany the Arkansas 10 336 form.

• Application for Special License Plate: This form is typically used to formally request a special license plate for individuals with disabilities. It includes personal information and details about the vehicle.
• Physician’s Statement of Disability: This document provides a detailed account from a licensed physician regarding the individual's disability. It serves as a crucial piece of evidence to support the claims made in the Arkansas 10 336 form.
• Proof of Residency: Applicants may need to submit documentation that verifies their residency in Arkansas. This can include utility bills, lease agreements, or bank statements showing the applicant's name and address.
• Vehicle Registration Document: A copy of the vehicle registration is often required. This document confirms that the vehicle for which the special license plate is being requested is registered in the applicant's name.
• Identification Document: A government-issued ID, such as a driver’s license or state ID, is necessary to verify the identity of the applicant. This helps ensure that the application process is secure and legitimate.

Being prepared with these documents can significantly enhance the efficiency of your application process. Ensuring that all necessary forms are completed accurately and submitted together will help avoid delays and potential complications. Always check with the relevant authorities for any updates or additional requirements that may apply.

The Arkansas 10 336 form serves as a certification for the issuance of special license plates or certificates for individuals with disabilities. Several other documents share similarities with this form in terms of purpose, structure, and the information they require. Below is a list of seven such documents:

• ADA Paratransit Eligibility Application: This application is used to determine eligibility for paratransit services under the Americans with Disabilities Act. Like the Arkansas 10 336 form, it requires detailed information about the applicant's disability and mobility limitations.
• State Disability Parking Permit Application: This document is required to apply for a disability parking permit in various states. Similar to the Arkansas 10 336 form, it necessitates a physician's certification of the applicant's disability and includes specific criteria that must be met.
• Social Security Administration Disability Benefits Application: Individuals seeking disability benefits must complete this application, which includes medical documentation and personal information. Both forms aim to establish the nature and extent of the applicant's disability.
• Medicaid Disability Application: This application is used to determine eligibility for Medicaid based on disability. It shares the need for medical documentation and personal information, paralleling the requirements of the Arkansas 10 336 form.
• Veterans Affairs Disability Compensation Claim: Veterans seeking compensation for service-related disabilities must fill out this claim form. Both documents require verification of the disability and may involve similar medical assessments.
• State-Specific Disability Identification Card Application: Many states offer identification cards for individuals with disabilities. The application process often mirrors that of the Arkansas 10 336 form, requiring medical certification and personal details.
• Accessible Housing Application: Individuals seeking accessible housing often need to submit an application that includes information about their disability. Like the Arkansas 10 336 form, this document typically requires a physician's verification and outlines specific criteria for eligibility.

When filling out the Arkansas 10 336 form, it is essential to follow specific guidelines to ensure accuracy and compliance. Here is a list of things you should and shouldn't do:

• Do provide complete and accurate information for both the physician and the applicant.
• Do include the photo ID number or driver's license number of the person with a disability.
• Do circle the appropriate condition(s) that apply to the individual in Part 1.
• Do ensure that the physician signs and dates the form before submission.
• Don't leave any required fields blank; all information is necessary for processing.
• Don't provide false information or assist someone who does; this could lead to legal consequences.
• Don't forget to return the special certificate or plate if the person moves or passes away.
• Don't misuse the special license plate or certificate; doing so may result in penalties.

Understanding the Arkansas 10 336 form is crucial for those seeking a special license plate or certificate for persons with disabilities. However, several misconceptions surround this form. Let’s clarify some of these misunderstandings.

• Misconception 1: Only permanent disabilities qualify for a special license plate.

This is not true. The form accommodates both permanent and temporary disabilities. Individuals can receive a special certificate even if their disability is temporary, as long as it meets the specified criteria.

• Misconception 2: A physician's signature is optional.

In fact, a licensed physician must certify the individual’s disability. This certification is essential for both the applicant and the organization seeking the special plate or certificate.

• Misconception 3: The special license plate can be used by anyone.

This is a common misunderstanding. The special plate or certificate is only valid when the vehicle is used to transport the individual for whom it was issued. Misuse can lead to serious penalties.

• Misconception 4: There is no expiration for the special certificate.

On the contrary, the special certificate for permanently disabled individuals expires four years after issuance. Temporary certificates expire three months after issuance. Renewal does not require re-certification for permanent disabilities.

When filling out the Arkansas 10 336 form, there are several important points to keep in mind. Understanding these can help ensure a smooth application process for a special license plate or certificate for individuals with disabilities.

• Part 1 and Part 2: Determine whether you need to complete Part 1 or Part 2 of the form. Part 1 is for licensed physicians certifying an individual, while Part 2 is for organizations providing transportation for persons with disabilities.
• Required Information: Be prepared to provide essential details such as the name and address of the physician or organization, as well as the name and address of the person with a disability.
• Disability Certification: The physician must certify the individual's disability, indicating whether it is permanent or temporary. Specific conditions must be checked off to validate the claim.
• Photo ID Requirement: Include the photo ID number or driver’s license number of the person with a disability. This information is crucial for statistical tracking and identification.
• Display of Certificate: Once obtained, the special certificate must be displayed properly in the vehicle, either on the inside rearview mirror or dashboard.
• Consequences of Misuse: Be aware that providing false information or misusing the privileges granted by the special license plate or certificate can lead to serious penalties, including fines and misdemeanor charges.
• Expiration and Renewal: Note the expiration terms. The special certificate for permanently disabled individuals lasts four years, while the temporary certificate is valid for three months. No re-certification is needed for renewal of the permanent certificate.