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Pothole Damage Complaint

  1. 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.
  2. Is the Claimant the same person as the Operator?*
  3. Incident Location
  4. Claimant Current Address
  5. Operator Current Address (if different from Claimant)
  6. 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]
  7. Please Attest*
  8. Leave This Blank:

  9. This field is not part of the form submission.