Town of Lincoln, Rhode Island webinfo@lincolnri.org 100 Old River Road, Lincoln, RI, 02865, US 401-333-1100 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? Choose One Yes No Date of Incident Month MM January February March April May June July August September October November December Day DD 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year YYYY 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 Time of Incident Incident Location / Reference Points ( IE: Pole #'s, Intersections, Landmarks , Mile Markers ect.. ) Street Address City State Choose State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Claimant Phone Number Claimant Email Claimant Current Address Street Address City State Choose State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Vehicle Operator's Full Address (if different than claimant's address) Street Address City State Choose State Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Federated States Of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip Vehicle Registration Number Vehicle Mileage Vehicle State Registered Alabama - AL Alaska - AK Arizona - AZ Arkansas - AR California - CA Colorado - CO Connecticut - CT Delaware - DE Florida - FL Georgia - GA Hawaii - HI Idaho - ID Illinois - IL Indiana - IN Iowa - IA Kansas - KS Kentucky - KY Louisiana - LA Maine - ME Maryland - MD Massachusetts - MA Michigan - MI Minnesota - MN Mississippi - MS Missouri - MO Montana - MT Nebraska - NE Nevada - NV New Hampshire - NH New Jersey - NJ New Mexico - NM New York - NY North Carolina - NC North Dakota - ND Ohio - OH Oklahoma - OK Oregon - OR Pennsylvania - PA Rhode Island - RI South Carolina - SC South Dakota - SD Tennessee - TN Texas - TX Utah - UT Vermont - VT Virginia - VA Washington - WA West Virginia - WV Wisconsin - WI Wyoming - WY 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. Sign Here First Name Last Name Email Draw Type Meddon