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Town of Lincoln, R.I.

webinfo@lincolnri.org

100 Old River Road, Lincoln, RI, 02865, US

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.

Date of Incident

Incident Location / Reference Points ( IE: Pole #'s, Intersections, Landmarks , Mile Markers ect.. )

Claimant Current Address

Vehicle Operator's Full Address (if different than claimant's address)

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

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