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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:
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Upload file
Please submit a form of income verification:
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