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2. 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.
4. Claimant (Owner or Operator)*
6. Is the Claimant the same person as the Operator?*

   1. Yes
   2. No
8. Date of Incident*
   Date of Incident
10. Time of Incident
    Time of Incident
12. Incident Location
14. Street Address or Reference Points (i.e signs, poles)*
16. City*
17. State*
18. Zip/Postal Code*
20. Claimant Phone Number
22. Claimant Email
24. Claimant Current Address
26. Street Address*
28. City*
29. State*
30. Zip/Postal Code*
32. Operator Current Address (if different from Claimant)
34. Street Address
36. City
37. State
38. Zip/Postal Code
40. Vehicle Registration Number*
42. Vehicle Mileage*
44. Vehicle State Registered*
    -- Select One --AlabamaAlaskaArizonaArkansasCaliforniaConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
46. Description of Incident *
48. Damaged Property*
50. 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]
52. A copy of the valid RI registration for the vehicle (Attach a scan or image)*
54. Copies of itemized damage, paid receipts with proof of payment for the vehicle*
56. One of these three documents: a copy of police report, a toll receipt, or an auto club report*
58. Please Attest*

    1. 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
60. Sign Here:*
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62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit

* indicates a required field