2. 
4. Todays Date:*
   Todays Date:
5. Upload Information Here
7. First Name*
8. Last Name*
10. Address*
12. City*
13. State*
14. Zip Code*
16. Email Address*
17. Phone Number*
19. Time & Date of Incident*
    Time & Date of Incident

    Time & Date of Incident
20. Location: (Please include Poll # or House # nearest the pothole or incident to aid in our investigation)*
22. Describe Incident:*

24. Note: Pursuant to MGL Ch 84, Sec 18, your claim must be submitted within thirty days from the date of the incident. Use additional sheet of paper if necessary, for description of incident. Attach any paid bills or photos to help during investigation of your claim. Return completed form to 

    Alison Wood,- Mayor's  Office, 
    77 Park Street,
    Attleboro,    MA    02703

    or email to: legalsecretary@cityofattleboro.us.

    By giving you the opportunity to fill out a claim form does not constitute responsibility on the part of the City of Attleboro for this claim, nor does it mean that this claim will automatically be paid by the City of Attleboro This claim will be investigated by the proper department and a determination will then be made either by the City Attorney or the City's insurance company.

    
    

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