Fillable Pothole Claim Form Nov 2017 Fillable (City of Meriden (CT))

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Pothole Claim Form Nov 2017 Fillable (City of Meriden (CT))

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City of Meriden
142 East Main St.
Meriden, CT 06450-5605
Pothole Claim Form
Completed forms can be emailed to cityclerk@meridenct.gov or mailed/delivered to the City
Clerk at 142 East Main St., Meriden, CT 06450.
Date: _________________________________________________________________________
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Apt/Unit Number: ______________________________________________________________
City: _____________________________ State: ______ Zip Code: ______________________
Date of Incident: _______________________________________________________________
Describe Location:
______________________________________________________________________________
______________________________________________________________________________
Describe Damage – (i.e. – left front rim of tire)
______________________________________________________________________________
______________________________________________________________________________
Please attach a photo of the damage as well as an estimate/invoice/ other supporting
documentation.
Comments:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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Pothole Claim Form Nov 2017 Fillable (City of Meriden (CT))

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Completed 13 July 2020

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