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. American LegalNet, Inc. www.FormsWorkFlow.com STATE REASONS FOR APPEAL BELOW American LegalNet, Inc. www.FormsWorkFlow.com 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 American LegalNet, Inc. www.FormsWorkFlow.com