To Report a Lost or Stolen Permit (Please print all the ...

To Report a Lost or Stolen Permit (Please print all the information requested)

Permit Holders Name: __________________________________________________ Date of Birth: _______________________ Telephone#: _______________________ Home Address: ______________________________ Apartment #: ___________ City: _____________________________ State: _______ Zip Code: ____________

Permit Type? City _______________________ (Rectangle/Dashboard)

State ____________________________ (Blue or Red Hangtag/Rearview mirror)

Permit #(s) if known ______________________

_______________________________

Was permit lost? __________ stolen? _________ License Plate#___________________

Write a brief explanation below of why the permit is missing: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________

I declare, under penalties of the penal law Section 210.45, that the statements contained herein are, to the best of my knowledge and belief, true and correct and that I have not knowingly and willfully made a false statement or given information which I know to be false. Making a punishable false written statement is a Class A misdemeanor.

_________________________________________ Permit Holder's Signature (or guardian)

_____________________________ Date

Note: The permit holder must file a report with the local police precinct where the incident occurred and obtain a police incident information slip. Please make sure that the incident report states the nature of the crime and identify the type of permit as: NYC Disability Parking Permit or a NYS Hangtag as Lost or Stolen. This slip must be sent with this completed form to the Parking Permits for People with Disabilities (PPPD) Unit at the address listed below.

Special Instructions: On-Site pickup for permits call (718) 433-3100 for ID requirements

NYC Department of Transportation Permits & Customer Service (PPPD Unit)

30-30 Thomson Avenue, 2nd Floor Long Island City, NY 11101 T: (718) 433-3100, TTY (212) 504-4115 dot/permits

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