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Appeal Form. This is a Rhode Island form and can be use in Traffic Tribunal Statewide.
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Tags: Appeal Form, Rhode Island Statewide, Traffic Tribunal
STATE OF RHODE ISLAND
Rhode Island
AND PROVIDENCE PLANTATIONS
670 New London Avenue
Cranston, Rhode Island 02920‐3081
Traffic Tribunal
(401) 275‐2700
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
Date of Hearing
Location
Time
License Number
State
Work
Summons No. or Case No.
Date of Birth
ATTORNEY OF RECORD MUST FILL OUT THE FOLLOWING:
Name
Bar Registration Number
Address
City
State
Zip Code
Telephone No.
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STATE REASONS FOR APPEAL BELOW
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STATE OF RHODE ISLAND
Rhode Island
AND PROVIDENCE PLANTATIONS
670 New London Avenue
Cranston, Rhode Island 02920‐3081
Traffic Tribunal
(401) 275‐2700
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
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