Berkeley, CA · Alameda County
In-Home Care Permit Medical Affidavit Form
Attending physicians and healthcare professionals complete this form to apply for an In-Home Care Permit in a Residential Preferential Parking area.
What this form is
This form supports an application for an In-Home Care Permit in a Residential Preferential Parking (RPP) area. It asks the attending physician to identify the resident, address, RPP area, and period when health care is needed, then sign a statement under penalty of perjury. A healthcare professional also provides applicant details and may list up to three permits.
Who needs it
An attending physician and a healthcare professional complete the form for a resident seeking an In-Home Care Permit in an RPP area.
How to submit it
Submit the form to the Transportation Division’s Residential Preferential Parking Program; the form also names the Finance Department and Public Works Department.
About notarization
This form is signed without a notary; the attending physician and healthcare professional each make a declaration under penalty of perjury.
How to submit this form
- 1
Download The Form
Download the In-Home Care Permit Medical Affidavit PDF.
- 2
Complete The Form
Have the attending physician and healthcare professional enter the requested information and sign and date their statements.
- 3
Review Supporting Materials
The form does not list any attachments; review it to ensure all requested fields and signatures are provided.
- 4
Submit To The City
Submit the completed form to the Transportation Division’s Residential Preferential Parking Program.
Frequently asked questions
- What is the In-Home Care Permit Medical Affidavit for?
- It supports an application for an In-Home Care Permit in a Residential Preferential Parking area and includes statements from an attending physician and healthcare professional.
- Who completes the affidavit?
- The attending physician provides information about the resident and health-care need. A healthcare professional provides applicant details and may list up to three permits.
- Do I need a notary for the In-Home Care Permit Medical Affidavit?
- No. The form is signed without a notary, but the attending physician and healthcare professional each declare under penalty of perjury that their statement is true and correct.
- How do I submit the In-Home Care Permit Medical Affidavit?
- Submit it to the Transportation Division’s Residential Preferential Parking Program. The form also names the Finance Department and Public Works Department.
Need something notarized?
This In-Home Care Permit Medical Affidavit Form doesn’t need a notary — but if you have another Berkeley form that does, a commissioned online notary can help.