Free Appeals Proof for Service Form - Rhode Island

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