North Carolina Department Of Transportation Citizen Incident Statement printable pdf download

North Carolina Department Of Transportation Citizen Incident Statement

Form 141

Rev 12/1/2005

North Carolina Department of Transportation

Citizen Incident Statement

This form is designed to assist in reporting an incident resulting in damage or injury that involved the North Carolina Department

of Transportation.

GENERAL INFORMATION:

(Please fill out General Information for either vehicle incident or property incident)

Your Name: _______________________________________________________________________________

Your Address: ______________________________________________________________________________

City: _________________________________ State: _____________ Zip Code: _________________________

Telephone:

Business: (_______)____________________ Home: (______)_____________________________

Date of Incident: _____________ Time: _________ Location: ________________________________________

__________________________________________________________________________________________

State Agency Involved in Incident: _______________________________________________________________

State employee you consider responsible for the

Incident:____________________________________________________________

Address: ___________________________________________________________________________________

Explain in your own words how you were injured or damaged and in what way you believe the State employee was responsible.

North Carolina Department Of Transportation Citizen Incident Statement