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Blue Badge Application Form Your Blue Badge application is attached. Please complete all relevant sections of the application and supply the appropriate documents to confirm: your address, your identity and evidence of eligibility. When completing this form you may find the accompanying guidance notes helpful. We may have to return any incomplete applications. We will be unable to issue your blue badge if you do not provide the evidence that proves you meet the eligibility criteria.

The Sections in this form include: Section 1 - Information about you Section 2 - Applicants who may qualify automatically Section 3 - Applicants who are subject to further assessment with walking difficulties Section 3a - Mobility Assessment Section 4 - Applicants with a disability in both arms Section 5 - Applicants under the age of 3 Section 6 - An Organisational Blue Badge Section 7 - Further information, declarations and signatures (All Applicants) The fee for the issue of your Blue Badge is £10.00 and will only be taken if your application has been successful. Please do not send or make a payment when submitting your application. If you application is successful, we will contact you by telephone or letter to request payment. You can either:

Make a telephone payment when we call you.

Call into one of the Information Centres and make a payment once we have contacted you to confirm your application has been successful

Post us a cheque payment made payable to Northumberland County Council, once we have contacted you to confirm your application has been successful

When your form is complete you can call into one of our information centres where we can photocopy your evidence for you, and forward it to the Blue Badge Team on your behalf. Or you can post your form, evidence and to: The Blue Badge Team Northumberland County Council Wansbeck Square Ashington Northumberland NE63 9XL If you have any queries about your application please call us on: 0345 600 6400

Section 1 – Information about you

If you are completing the form on behalf of a child who is under 16 years of age, please provide their details. However you can sign the form on their behalf. If you are applying for an organisation that cares for and transports disabled people then please ONLY complete sections 6 and 7. Further help on completing this section can be found in Section 1 of the accompanying guidance notes. Title: (Mr, Mrs, Miss, etc)

First names: (In full)

Surname:

Surname at birth:

Gender: Male Female

Date of Birth: (DD/MM/YYYY)

National Insurance

No:

Child Registration No: Issued to people under 16 - Section 1

of guidance notes

Driving Licence No: (if applicable)

Current Address

Postcode

Town of Birth

`

Previous Address, if different in the last three years

Contact Details Email Address:

Home Telephone No:

Mobile Telephone No:

Do you currently

hold a Blue Badge?

Yes:

No:

Which Council issued your badge? What is the serial number on the badge? What is the expiry date of the badge?

Postcode

It is important that you complete all relevant sections of the application and that you supply the appropriate documents to confirm:

Your address

Your identity

Evidence of eligibility We may have to return any incomplete applications. We will be unable to issue your blue badge if you do not provide the evidence that proves you meet the eligibility criteria.

Proof of your address, dated within the last 6 months: We need to check that you are resident in this local authority area before we can process your application. Select one of the following and remember to provide copies of documents if applicable.

Or: I enclose a photocopy of a Council Tax bill or utility bill, with my name and address on, dated within the last 6 months

Either: I give consent to the local authority to check my personal details on the local authority Council Tax database so that I do not need to submit proof of my address

Or: I, or the applicant, does not pay Council Tax, but enclose proof of residency at the above address. (For example, Child Benefit award letter, Child Tax Credit award letter)

Proof of your identity: You must attach one of the following as proof of your identity: We need to check your identity to reduce the potential for fraudulent applications for Blue

Badges.

A photocopy of your Birth certificate/adoption certificate

A photocopy of your Marriage/ Civil Partnership Certificate

A photocopy of your Passport

A photocopy of your Valid Driving Licence

A photocopy of your UK residence permit/EEC identity card

Photograph Please enclose one passport-style photograph of the person applying for a Blue Badge. The photograph needs to show the full face of the applicant so that the holder can be easily identified and no-one else should be in the photograph. Please ensure that the applicant’s name is on the back of the photograph and that you complete Section 7.2 of the application

form to confirm that the photograph is a true likeness.

Section 2 – Applicants who qualify without further assessment

Section 2.1– Terminally Ill Section 2.2 – Higher Rate Mobility Component of Disability Living Allowance or Personal Independence Payment (with a score of 8 or more in the moving around section) Section 2.3 – Blind (severely sight impaired)

This section is intended for people who may automatically qualify for a Blue Badge because they:

Are terminally ill and hold a DS1500 report

Receive the Higher Rate Mobility Component of Disability Living Allowance

Are in receipt of Personal Independence Payment (PIP) and have scored 8 or more points in the moving around section.

Are registered severely sight impaired (blind)

Receive War Pensioner’s Mobility Supplement

Receive a qualifying award under the Armed Forces and Reserve Forces (Compensation) Scheme

If you are unsure whether these questions apply to you, please refer to Section 2 of the accompanying guidance notes.

Do you have a terminal illness AND hold a DS1500 report?

Yes No

Go to Section 2.2

If you answered YES, it is important that you provide us with a photocopy of your DS1500 report or a covering letter from your healthcare professional. Please read the Guidance Notes for the definition of healthcare professional. We cannot progress your application until we receive this. If you have applied under this section, please add “Blue Badge (Section 2.1)” when

addressing your envelope.

Do you receive the Higher Rate Mobility Component of Disability Living Allowance or PIP(scoring 8 or more –moving around)

Yes

No

Go to Section 2.3

If YES, have you been awarded this benefit indefinitely?

No

Yes

If NO, when is your award of this benefit due to end? Please note: We can only issue a Blue Badge up to this date if you are applying under this section.

If you answered YES, you must enclose either:

a copy of your award letter for this benefit, if it is dated within the last 12 months

or; a copy of your most recent annual uprating letter. We cannot progress your application until we receive this.

Please note that we may also check that you are in receipt of this award with the Department for Work and Pensions.

Have you attached a photocopy of your award

letter or most recent annual uprating letter?

Yes

Go to section 7

Have you attached your DS1500 report?

Yes - Go to section 7

Section 2.3 – Blind (severely sight impaired) Section 2.4 – War Pensioner’s Mobility Supplement Section 2.5 – Benefit under the Armed Forces and Reserve Forces (Compensation) Scheme

Are you blind (severely sight impaired)?

Yes

No Go to Section 2.4

If you are registered blind with a local authority, please state which one you are registered with:

If registered with Northumberland County Council, do you give us consent to check our register of blind people to see whether your disability is already known to the Council?

No

Yes

If you are not registered blind with a local authority, or you are registered blind with a different local authority - you must attach a copy of your Certificate of Vision Impairment (CVI) or a BD8 form signed by a Consultant Ophthalmologist, to this application. We cannot progress your application until we receive this.

Do you receive the War Pensioner’s Mobility Supplement?

Yes

No

Go to Section 2.5

If you answered YES, you must enclose either:

a copy of your letter of entitlement to this benefit, if it is dated within the last 12 months

or; a copy of your most recent annual uprating letter. You will have an award letter from the Service Personnel and Veteran Agency (SPVA). If you have lost this letter, then the agency can be contacted via free-phone on: 0800 169 22 77. We cannot progress your application until we receive this.

Have you attached a photocopy of your CVI or BD8?

Yes - Go to section 7

Do you receive a lump sum benefit under the Armed Forces and Reserve Forces (Compensation) Scheme within tariff levels 1-8 (inclusive) and have been certified by the SPVA as having a permanent and substantial disability which causes inability to walk or very considerable difficulty walking?

Yes

No Go to

Section 3

If you answered YES, the Service Personnel and Veterans Agency (SPVA) will have issued you with a letter confirming the level of your award and also confirming that you have been assessed as having a permanent and substantial disability which causes inability to walk or very considerable difficulty in walking. You must enclose a copy of this letter as proof of entitlement. If you have lost this letter, then the agency can be contacted via free-phone on: 0800 169 22 77. We cannot progress your application until we receive this.

Have you attached a photocopy of your letter of entitlement or most recent annual uprating letter?

Yes - Go to section 7

Have you attached a photocopy of your letter of entitlement?

Yes - Go to section 7

Section 3 – Applicants who are subject to further assessment with walking difficulties

Section 3.1 – Medical Conditions/disabilities

These questions are intended for people who have answered NO to all of the questions in Section 2. You will only qualify for a Blue Badge under this criterion if you, or the person you are applying for, are over two years of age and:

have a permanent and substantial disability which means you are unable to walk;

or, you have very considerable difficulty in walking Under this criterion, Blue Badges are only issued to people who are unable to walk at all, or who demonstrate very considerable difficulty in walking due to a permanent and substantial disability. If you are unsure whether these questions apply to you, please refer to Section 3 of the accompanying guidance notes. You will be required to provide us with a letter from a healthcare professional confirming the medical or joint conditions or disabilities that you have stated. Please see the guidance notes for more information on health care professionals.

Do you have any of the listed medical conditions or disabilities? Please tick all that are applicable. If you have one or more of the conditions listed please tick and go straight to section 3.3. If you have none of the conditions listed please go to Section 3.2: Joint

conditions.

Angina

Breathlessness/Breathing Difficulty

Cerebral Palsy

Chronic Bronchitis Chronic Obstructive Airways Disease (COPD)

Emphysema

Heart Failure

Huntington’s Disease

Lower Limb Amputation

Motor Neurone Disease

Multiple Sclerosis

Muscular Dystrophy (affecting lower limbs)

Neurological Problem

Osteoporosis

Paralysis/Left or right sided weakness

Poor Mobility/Balance/Falls

Terminal Illness

Other (Please specify)

None of the above (Go to Section 3.2)

Section 3.2 – Joint Conditions/Disability Section 3.3 – Proof of Medical/Joint condition or disability

Do you have any of the listed joint conditions? Please tick all that are applicable.

Arthritis

Hip Replacement

Joint Pain

Knee Replacement Osteo Arthritis

Rheumatoid Arthritis

Other (Please specify)

None of the above Go to Section 4

Have you had a lower limb operation in the last 3 months?

Yes

No

Has your GP/Specialist recommended or booked you any lower limb operations within the next 6 months?

Yes

No

Have you attached a document from a healthcare professional? Please see the guidance notes for more information on health care professionals.

Yes

Go to section 3a

You will be required to provide us with a document from a healthcare professional confirming the medical and/or joint conditions or disabilities that you have stated. We cannot progress your application until we receive this.

If you have answered yes to either of the two questions directly above, was the purpose of this operation specifically to improve your mobility.

Yes

No

Section 3a – Mobility Assessment Section 3a.1 –Your condition Section 3a.2 – General walking ability

You should only complete this section if you have any of the Medical or Joint conditions or disabilities listed in Section 3. Please do not complete this section if you

Answered yes to any of the questions in Section 2.

Are applying because you have a disability in both arms

Are applying for a child under the age of 3

Are applying for an Organisational Blue Badge

There is more help in Section 3a of the attached guidance notes.

Is your condition likely to last more than 12 months?

Yes

No Don’t know

Please tick one of the following statements which best describes your general walking ability. If you use walking aids please describe your general walking ability with the use of these aids.

I am able to walk well, including recreational walks

I am able to walk around the supermarket to do my own shopping

I am able to walk and can use public transport for some of my local trips

I am able to walk but struggle with longer distances or hills

I am able to walk but get breathless if I walk for more than a few minutes

I am able to walk but find it too painful to walk for more than a few minutes

I am able to walk, but use a wheelchair for long trips outside my home

I am able to walk around my home, but am unable to climb the stairs

I am unable to walk at all

Tick one box only Tick the box which best describes your general walking ability.

Section 3a.3 – Walking aids Section3a.4 – How far can you walk? Section3a.5 – The way in which you walk

Do you use any of the following when you are walking? (Please tick whichever options apply to you)

1 elbow crutch or 2 elbow crutches

1 walking stick or 2 walking sticks

Walking frame (Zimmer frame)

Rollator

Wheelchair

Powered wheelchair

No walking aids used

When answering “how far would you estimate you are able to walk before you feel severe discomfort”, please note:

The average adult step is just less than one metre, which is 1.1 yards or 3 feet 4 inches

If you walk alongside someone and they take 100 steps you would have walked roughly 90 metres, or 100 yards

The average double-decker bus is about 11 metres, or 12 yards long

A tennis court is about 24 metres, or 26 yards long

A full sized football pitch is about 100 metres, or 110 yards long If you are unsure, ask someone to walk with you and pace the distance that you walk.

How far would you estimate you are able to walk before you feel severe discomfort?

: metres

: yards

(Please state either metres or yards using whichever measure is best for you)

Roughly how much time would you estimate it takes you to walk this distance?

: minutes

Please tick the box that best describes the way you walk:

Normal: No specific problems with walking

Adequate: For example you walk with a slight limp

Poor: For example, you walk with a heavy limp, a stiff leg or a shuffle, or have problems with balance

Extremely poor: For example, you drag your leg, stagger, swing through two crutches or need physical support

Not Applicable: Unable to walk at all

Tick one box only - tick the box which best describes the way in which you walk.

Please go straight to Section 7 – Further information, declarations and signatures

Section 4 – Applicants with a disability in both arms Section 4.1 – Driving Section 4.2 – Your disability Section 4.3 – Parking metres/pay and display machines

Please only complete this section if you, or the person on whose behalf you are applying:

Drive a vehicle regularly

Have a severe disability in both arms

And are unable to operate, or have considerable difficulty operating, parking meters or pay and display machines.

Please note you will only qualify under this section if you meet all of the above. If you are unsure whether these questions apply to you, please refer to Section 4 of the accompanying guidance notes.

Do you drive regularly? Yes

No

Go to Section 5

Do you have a severe disability in both arms?

Yes

No

Go to Section 5

Are you unable to operate, or have considerable difficulty operating, parking meters or pay and display machine due to your upper limb disability?

Yes

No

Go to Section 5

If yes, please describe the difficulties you have with operating parking meters and pay and display machines

Please describe your medical condition. (Please tick whichever options apply to you)

Limb reduction or deficiency in both arms

Bilateral upper limb amputation

Muscular Dystrophy

Spinal cord injury Motor neurone disease

Thalidomide

Or another condition of considerable comparable severity (Please describe in the space below)

Cerebral Palsy (upper limbs)

Section 4.4 – Specially adapted vehicles Section 4.5 – Proof of your disability

If yes, please describe how the vehicle has been adapted for you, and enclose a copy of your insurance details verifying the adaptations

Have you attached a letter from a healthcare professional? Please see the guidance notes for more information on health care professionals.

Yes

Go to section 7

You will be required to provide us with a letter from a healthcare professional confirming the disabilities that you have declared We cannot progress your application until we receive this.

Do you drive a specially adapted vehicle? Yes

No

Section 5 – Applicants who are under the age of three

Section 5.1 – Bulky equipment

Section 5.2 – Necessary treatment Section 5.3 – Proof of Child’s treatment on 6 – Organisational Blue Badge

Section 6 – Organisational Blue Badge

This section is for children under the age of three who may be eligible for a Blue Badge because:

They have a condition requiring the transportation of bulky medical equipment at all times

Or, they must always be kept near a motor vehicle on account of a condition so that they can, if necessary, be treated for that condition in the vehicle or taken quickly in the vehicle to a place where they can be treated.

If you are unsure whether these questions apply to your child, then please refer to Section 5 of the accompanying guidance notes. Are you applying on behalf of a child under the age of three who has a condition requiring transportation of bulky medical equipment at all times?

Yes

No

Are you applying on behalf of a child under the age of three that suffers from a condition that requires that they must be always kept near a vehicle so that they can, if necessary, be treated for that condition in the vehicle or be taken quickly to a place where they can be treated?

Yes

No

Please enclose a letter from a healthcare professional that has been involved in your child’s treatment (for example your paediatrician) giving details of your child’s medical condition and the type of medical equipment they need. We cannot progress your application until we receive this. Have you attached a letter from a healthcare professional? Please see the guidance notes for more information on health care professionals.

Yes - Go to section 7

If yes, please indicate what type of equipment. (Please tick whichever options apply to you)

Ventilator

Feed pump

Suction machine

Parenteral equipment Syringe drivers

Oxygen administrative equipment

Casts or medical equipment for hip dysplasia

Oxygen saturation monitoring

If yes, please indicate what type of equipment. (Please tick whichever options apply to you)

Tracheotomy Severe epilepsy or fitting

Highly unstable diabetes

Terminal Illness Syringe drivers

Other serious condition (Healthcare supported) Please describe

Section 6 – Organisational Blue Badge Section 6.1 – Organisation details Section 6.2 – Care provided Section 6.3 - Type of vehicles and frequency of use

This section is for applications for an Organisational Blue Badge They will only be issued to an organisation which:

Cares for and transports disabled people who would meet one or more of the eligibility criteria for an individual Blue Badge: and

Has a clear need for an organisational badge rather than using the individual Blue Badges of the people who are being transported.

If you are unsure whether these questions apply to your organisation, please refer to Section 6 of the accompanying guidance notes.

Does your organisation care for disabled people who would themselves qualify for an individual Blue Badge?

Yes

No

As part of the care, does your organisation provide them with transportation?

Yes

No

Name of

Organisation

Main contact name

Current Address

Postcode

Email Address: Home Telephone No:

If yes, please give details of the nature of this care

If yes, please give details of the types of vehicles used and how often they are used to transport disabled people

Type of Vehicle

Frequency used

Section 6.4 – Disabled Passenger Vehicle

Section 6.5 –Further information Section 6.6 – Evidence

Are any of your vehicles licensed under the Disabled Passenger Vehicle (DPV) taxation class?

Yes

No

If yes, please give details and attach a photocopy of the tax disc(s) to this application

How many disabled people are in the care of your organisation?

: people

How many of these people are already in receipt of a Blue Badge as individuals?

: people

How many of these people do you estimate would be eligible to receive a Blue Badge if they applied as individuals? See description of eligible people in the accompanying guidance

: people

Please describe why your organisation is applying for a Blue Badge and the types of trips it will be used for.

How often do you think your organisation will use the Blue Badge? If you already have an organisational

Blue Badge:

What is the serial number on the current badge(s)?

What is the expiry date of the current badge(s)?

How many organisational badges are you applying for? (Please note that you will be required to pay the £10 badge issue fee for EACH organisational badge issued)

Please provide the Vehicle Registration Numbers of the vehicles in which you intend to use the Blue Badge:

Please note we will not issue Blue Badges for staff members own cars. Please attach a declaration on Organisational Letterhead confirming that the organisation does care for disabled people, who would meet one or more of the criteria, and that they will only be using the badge solely for the purpose of transporting those people. If you answered Yes to 6.4 Disabled Passenger Vehicle, you must attach a copy of the tax disc(s) to this application if your vehicles are licensed under the Disabled Passenger Vehicle (DPV) taxation class. We cannot progress your application until we receive these.

A copy of the tax disc(s) to this application if your vehicles are licensed under the Disabled Passenger Vehicle (DPV) taxation class.

Yes - Go to section 7

Have you attached a Declaration on Organisational Letterhead?

Yes

Section 7 – Further information, declarations and signatures Section 7.1 Further information Section 7.2 – Mandatory declarations Section 7.3 – Optional declarations

This section is to be completed by ALL applicants. Your application will not be processed if this section is not completed and the relevant

evidence has not been provided

Is there anything else you can add that you think is relevant in support of your Blue Badge application?

Please carefully read the following declarations. Please read each statement and place a tick in each white box to indicate that you have read, understand and agree with each declaration. Not ticking one of these boxes may mean we are unable to issue you with a Blue Badge

I confirm that, as far as I know, the details that I have provided are complete and accurate. I realise that you may take action against me if I have provided false information in this application form.

This section contains the mandatory declarations you must answer about the information you have provided and the application process.

I confirm that the photograph I have submitted with my application is a true likeness of myself.

I confirm that I do not currently hold a Disabled Person’s Parking Badge that has been issued by a different local authority. I understand that I must promptly inform Northumberland County Council of any changes that may affect my entitlement to a badge. I understand that you will deal with all documents relating to this application in line with the Data Protection Act 1998, and you may share them with other local authorities, the police and parking enforcement officers to detect and prevent fraud. I understand that the medical information I have supplied to support this application is deemed to be “sensitive personal data” and I consent to its disclosure only to a third party who is responsible for the operation and administration of the Blue Badge scheme and other Government Departments or agencies to validate proof of entitlement. I agree to Northumberland County Council contacting an accredited healthcare professional if necessary, for the purpose of obtaining further information in support of my application.

I understand that I may be required to undertake a mobility assessment with a healthcare professional, who is independent of my existing care and treatment, to determine my eligibility. I agree that, if my application is successful, I will not allow any other person to use the badge for their benefit and I agree that I will use the badge in accordance with the rules of the scheme as set out in the “Blue Badge Scheme: rights and responsibilities” leaflet which will be sent to me with the badge.

Section 7.3 – Optional declarations Section 7.4 – Your signature When you have filled in your form and gathered your evidence please send them to: The Blue Badge Team Northumberland County Council Wansbeck Square Ashington Northumberland NE63 9XL

If you need this information in Large Print, Braille, Audio, or

in another format or language please contact us:

Telephone 0345 600 6400

Fax 01670 620098

Text phone 01670 542999

Text Relay 18001 0345 600 6400

Email bluebadges@northumberland.gov.uk

This section contains optional declarations about the information you have provided and the application process.

Please carefully read and tick the following optional declarations that you consent to. Ticking these boxes will help improve the service we can offer you.

I consent to Northumberland County Council checking any information already held by the Council’s Social Care department on the basis that:

It can help determine my eligibility for a Blue Badge

It may speed up the processing of my application

It may enable a decision to be made without the need for a mobility assessment

I agree to the disclosure of the information included in this form to other council departments/service providers so that I can be informed about other council services that may be of benefit to me.

Your signatures are required against the mandatory declarations (7.2) and the optional declarations (7.3) you have made.

We will not be able to progress your application if you have not signed your application.

Signature:

Date of application:

Please print your name:

Checklist of documents `

Please ensure that you have enclosed all of the relevant documents for the sections of the application form that you have completed. We have provided a checklist below to help remind you of what you need to enclose. Section 1 – Information about you

A photocopy of your proof of your address, dated within the last 6 months (only if you have not given your consent for us to check the Council Tax records) Or, if not eligible to pay Council Tax (e.g. applying on behalf of a minor), proof of residency (e.g. Child Benefit award letter, Child Tax Credit award letter) A photocopy of one form of proof of identity

A passport-sized photograph of yourself with your name on the back.

Section 2.1 – Terminally ill

A signed photocopy of your DS1500 report or a covering letter from a healthcare professional.

Section 2.2 – High Rate Mobility Component of DLA or PIP

A photocopy of your original award letter for the Higher Rate Mobility Component of Disability Living Allowance or PIP issued within the last 12 months or an original copy of your latest uprating letter.

Section 2.4 – War Pensioner’s Mobility Supplement

A photocopy of your original letter of entitlement for the War Pensioner’s Mobility Supplement

Section 2.5 – Benefit under the Armed Forces and Reserve Forces

(Compensation)

A photocopy of your original award letter confirming receipt of tariffs 1- 8 under the Armed Forces and Reserve Forces (compensation) Scheme which also certifies that you have a disability which causes inability to walk or very considerable difficulty walking.

Section 3.1 & 3.2 – Medical and Joint conditions or disabilities

A letter from a healthcare professional confirming the medical or joint conditions or disabilities stated.

Section 4 – Disability in both arms

A document from a healthcare professional confirming your disability. Please see the guidance notes for more information on health care professionals.

Section 5 – Children under the age of three

A letter from a healthcare professional involved in your child’s treatment giving details of condition and type of medical equipment needed.

Section 6 – Organisational Badge

A copy of the tax disc(s), if your vehicles are licensed under the Disabled Passenger Vehicle (DPV) taxation class.

A Declaration on Organisational Letterhead

Section 2.3 – Blind (severely sight impaired)

A photocopy of your CVI/BD8 form

Tick