Free Appeal Form - DMV Appeals - Rhode Island

STATE OF RHODE ISLAND
Rhode Island Traffic Tribunal



AND PROVIDENCE PLANTATIONS
670 New London Avenue Cranston, Rhode Island 029203081 (401) 2752700

APPEAL FORM
Rhode Island General Laws §§ 8-18-9, 31-41.1-8 or 31-31-2 establishes the right to appeal within to (10) days of notice of decision. The fee for this appeal is twenty-five ($25.00) dollars. You must complete this form and state your reasons for this appeal on the second page of this form. (Attach additional pages if necessary.) If your appeal does not show sufficient grounds, it will be denied. Failure to file this APPEAL FORM and pay the fee within ten (10) days of decision will deny your opportunity for an appeal. This is an appeal from a decision by: ( ) Traffic Tribunal ( ) Municipal Court ( ) Registry of Motor Vehicles Safety Responsibility Section

COMPLETE THE FOLLOWING: ______________________________________________________________________________
Last Name First Name MI

______________________________________________________________________________
Address (Number and Street, City, State and Zip Code) Telephone # Home Work _____________________________________________________________________________________________ Date of Hearing Location Time Summons No. or Case No. _____________________________________________________________________________________________ License Number State Date of Birth

ATTORNEY OF RECORD MUST FILL OUT THE FOLLOWING:
_____________________________________________________________________________________________ Name Bar Registration Number _____________________________________________________________________________________________ Address _____________________________________________________________________________________________ City State Zip Code Telephone No.

STATE REASONS FOR APPEAL BELOW

__________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________

STATE OF RHODE ISLAND
Rhode Island Traffic Tribunal



AND PROVIDENCE PLANTATIONS
670 New London Avenue Cranston, Rhode Island 029203081 (401) 2752700





PROOF OF SERVICE FORM
FOR CASE NUMBER (OR SUMMONS NUMBER):______________________________ COURT DATE: ______________________

I hereby certify that on__________________I served a certified copy of the APPEAL FORM to: ( ) ( ) ( ) Department of the ATTORNEY GENERAL (for Breathalyzer Cases Only) POLICE DEPARTMENT (For Traffic Tribunal or Municipal Court Appeals) REGISTRY OF MOTOR VEHICLES (For Safety Responsibility Appeals)

____________________________________________________
Appellant's Name

____________________________________________________
Signature

Serve By:__________________

ACKNOWLEDGMENT OF SERVICE
On ___________________I acknowledge receipt of service of the CERTIFIED COPY of the PETITION FOR REVIEW OF AGENCY DECISION.

_____________________________________
Signature

_____________________
Date