Skip to page content
Skip to global navigation
Skip to sub-navigation
Skip to search
Skip to page heading
Skip to breadcrumb
Skip to main content
Skip to footer
Top of Page
Skip to all departments
Site Map
Home Page
Accessibility Statement and Access Key Legend
Skip to help
Start of Category Links
Government
Business
Nonprofits
Community
Visitors
City Services
Mobile Apps
End of Category Links
Skip To End Of Global Navigation
Search Box
Search and City Services
Search & City Services
Google Search
Pay Online
Building inspections
JEA bill
Parking citations
Taxes
Traffic citations
More...
Apply / Register
Building Permits
Homestead Exemptions
Jobs
Marriage License
Park Reservation
More...
File / Report
Court e-filing
File a Complaint (630-CITY)
Police Report
Service Requests (630-CITY)
Find
City Calendar
Legislative Bill Search
Maps
Missing Pets
Parking
Parks & Amenities
Property Search
Offices / Departments
Link to All Departments Page
Focus to close search box
City of
Jacksonville
, Florida
Government
Mayor's Office
630-CITY
City Council
Investor Relations
Courts / Legal
Boards & Commissions
Public Safety
Constitutional Officers
Independent Authorities & Agencies
Ordinance Code
City Departments
Other Elected Officials
Community Redevelopment Area Board
Business
Starting a Small Business
Expanding/Relocating a Business
Doing Business with the City
JSEB
Vendor Search
Maps
Business Resources
Nonprofits
Grant Opportunities
Letters of Support
Contacts
Mailing List
FAQ
Community
Experience Jax
Daily Resources
Maps
Safer Communities
Neighborhood Blight
Citizens Planning
Visitors
Experience Jax
Special Events (JaxHappenings)
Resources
Maps
Sports
City Services
Pay a Fee
Public Safety
Request a Service
Apply/Register
Find
Event Permitting
Maps
Mobile Apps
JaxSheriff
MyJax
JaxLibrary
JaxHapps
JaxReady
Jacksonville Sheriff's Office
Directory
Contact Us
Inmate Search
Careers
Crime Tips
Notices
COJ.net
JaxSheriff.org
JSO
Help
Search
Would you like to view this page in desktop format?
Yes
No
Side Navigation Menu
Sub-Navigation Menu Start:
ADA Coordinator
ADA Grievance Procedure
ADA Technical Support
Employment
Facilities
Information and Communication Technology
Disabled Parking Citations
Events
ADA Symposium
Calendar
Fun with the Shrimp
Hiring Abilities
2017 Employment Symposium Registration
2017 Job Fair Registration
Information and Technology Symposium
Olympic Day
Spirit of the ADA
Mayor's Disability Council
Community Employee Award
Partnerships
ILRC of Northeast Florida
Jacksonville Job Corps
Library
North Florida MS Society
Transportation
Programs and Services
Adaptive Recreation
Athletics
Baseball
Basketball
Brooks Rehabilitation
Cycling
Football
Goalball
Kayaking
North Florida MS Society Wellness Program
Soccer
Surfing
Swimming
Tennis
Disabled Parking
Submit Hours
Volunteer
Volunteer Application Form
Permits
Do's and Don'ts
Legislation
Jim Brady Scholarship
Jim Brady Scholarship Apply Online
Title III Support Program
Wheelchair Ramp Program
Wheelchair Repair Assistance
Wheelchair Repair Apply Online
Resources
Audible Pedestrian Signals
Directory of Services for People with Disabilities
Election Concerns
Emergency Preparedness for Special Needs
Mental Health
Service Animals
White-Cane Law
Contact Us
For sitemap menu
options click on the
top tab
Social Media Links
Translate Menu
Translate
English
English
Site Search Tab
Back To Top
City of Jacksonville
Navigation
COJ.net
>
Departments
>
Parks, Recreation and Community Services
>
Disabled Services
>
Programs and Services
>
Wheelchair Repair Assistance
>
Wheelchair Repair Apply Online
Wheelchair Repair Apply Online
Last Name:
First Name:
Address:
City:
State:
Zip:
Home Phone:
(
)
-
Second part
Third part
Alternate Phone:
(
)
-
Second part
Third part
Email Address:
Are you a resident of Duval County?:
Yes
No
Is this your only wheelchair?:
Yes
No
If no, is the second wheelchair manual?:
Yes
No
Explain if no:
Do you have medical insurance?:
Yes
No
Have you been told by the Insurance Company that these items are not covered? If yes, why?:
Alternative means to repair?:
Yes
No
Number of persons in your household:
What is your current household income?:
What type of device needs to be repaired? Manual, electric, etc.:
Brand/Manufacturer:
Model number:
Serial number:
Age of Equipment:
What needs to be repaired?:
Please submit a copy of your identification:
Upload:
Upload file
Please submit a form of income verification:
Upload:
Upload file
Footer
