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Town of Lincoln, R.I.

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

**********Town of Lincoln, R.I.********** POTHOLE DAMAGE COMPLAINT FORM

Please fill this out ONLY in order to file a claim for reimbursement for vehicular pothole damage sustained upon town roads within The Town of Lincoln, R.I.

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; or A toll receipt; or An auto club report

Please Attest

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