Pothole Damage Complaint Form for Town Roads Only

Please complete this form to file a claim for reimbursement for vehicular pothole damage sustained on town roads within the Town of Lincoln, Rhode Island. Claims may not be made for damage occurring on State roads, such as highways and state routes.

Claimant [Owner or Operator]

Is the Claimant the same person as the Operator?

Time of Incident

Claimant Phone Number

Claimant Email

Vehicle Registration Number

Vehicle Mileage

Vehicle State Registered

Incident (Please detail what occurred; when it occurred; and how the damage was sustained)

Damaged Property [ List item name and damage sustained]

Please attach support records and data: [IE: Copy of Accident Report, Pictures of the scene of the damage, pictures of the damaged property, copies of original receipts, bills, or parts purchased, statements or other supporting materials]

A copy of the valid R.I. registration for the vehicle [Attach a scan or image]

Copies of itemized damage, paid receipts with proof of payment for the vehicle

One of these three documents: a copy of police report, a toll receipt, or an auto club report

Please Attest

The above information provided on this form is true and accurate to the best of my knowledge. Any fraud or material misrepresentation related to this claim for restitution may be enforced under Rhode Island Civil or Criminal Law.

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