Notice of Deficiency
This
form is intended to report any municipal deficiency, hazard or lack of
enforcement on public or private property. This will put on notice the
city/village/town /county, state or federal agency responsible for maintenance,
repair or enforcement that there is a deficiency that poses a danger to
citizen(s) named herein. If action is not taken to remedy or remove the
deficiency, then any person who is harmed has the right to claim damages for
injury to their person, vehicle or both from the municipal government in whose
jurisdiction the deficiency is located. Legal action may also be appropriate
whether a deficiency report has been filed no not. If in doubt, consult a
lawyer.
Who is reporting (Name)_______________________________________________________________
Address:_____________________________________________________Phone __________________
E-mail
Address:______________________________________________________________________________
What: (Hazard)deficiency – be specific______________________________________________
______________________________________________________________________________
When: Deficiency encountered/noticed____________________________________________________
Where: Location, (be specific) Street Name, Route Number, address, city, town etc. utility pole number, road mileage marker, or diagram if needed. Use back of this form or attach additional sheets to this report form if necessary.
[ ]. (Please see back of this form) Use back of form if needed for more detailed information.
What remedy do you suggest to correct this deficiency?________________________________________
Have you suffered loss or injury as a result of this hazard? Yes No (circle one)
What happened?________________________________________________________________________
Did you seek medical help? Yes No (circle one)
What was the medical outcome?____________________________________________________________
You
may wish to make a record of this filing. Make a duplicate copy for your files.
Keep a copy or record of your report and monitor the repairs or remedy you have
suggested.
Types of deficiencies include but are not limited to: pot holes, broken pavement, large cracks or holes in pavement, no curb cut, wide gaps in expansion joints on bridges etc., wide gap or drop-off in pavement joints at edge of road, broken shoulder, gravel and debris (broken glass, etc) on pavement or shoulder, standing water (clogged drains), hole formed from utility covers not at grade, dangerous storm drain grates, snow covered, broken or uneven sidewalk, double parked cars, cars blocking crosswalks, dangerous cross walks due to right turn on red, speeding cars, derelict, abandoned and/or boarded up houses and buildings, littered vacant lots, loud radios or other noise exceeding acceptable levels, or any deficiency that poses a hazard. This includes the failure of police to uniformly enforce the rules and regulations of the road for all users.
·
Report should be filed with the appropriate government agency. (Call
city or town clerk if in doubt.)
·
Governments can be and have been successfully sued for what they DO or
DO NOT DO
This form is provided as a
courtesy by Citizens for a
Revised