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DOCKET NUMBER
zz cy Y95~
Trial Court of Massachusetts
CIVIL ACTION COVER SHEET
PLAINTIFF(S):
The Superior Court
lcouNTY
w/
ADDRESS: Borastabl.
DEFENDANT(S):
for Es
rent oe
ATTORNEY:
ADDRESS: Sis 3 Klaeriy Poasl
D6 Gere Bea We
(92.502.
BBO: Lets! 64 TYPE OF ACTION AND TRACK DESIGNATION {see reverse side)
og cl Accdeons “F
CODE NO. TYPE OF Al CcON (specify)
lh
HAS A JURY CLAIM SEEN MADE?
uur To Ous fit ves (1xo
“If "Other" please describe:
is there a claim under G.L. c. 93A7 Js this a class action ler Mass. R. Civ. P. 237
| YES: NO
STATEMENT OF DAMAGES PURSUANT TO GL. c. 212, § 3A
{The following is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiffs counsel relies to determine money damages.
For this form, disregard double or treble damage claims; indicate single damages only.
TORT CLAIMS
(attach additional sheets as necessary) °
\A, Documented medical expenses to date:
1. Total hospital expenses:
2. Total doctor expenses
3. Total chiropractic expenses
4. Total physical iherapy expenses
5. Total other expenses (describe below) $5 OOO
Subtotal (A):
B, Documented lost wages and compensation fo date
IC. Documented properly damages to dale . .
D. Reasonably anticipated future medical and hospital expense:
E. Reasonably anticipated lost wages ..
IF. Other documented items of damages (describe below)
6. Briefly describe plaintiff's injury, including the nature and extent of injury:
TOTAL (A-FI$ OOOO
5D
LAIMS,
(attach additional sheets as necessary)
This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass. R. Civ. P. 8.1(a).
Provide a detailed description af claim(s):
TOTAL: $
Signature of Attorney/ Unrepresented Plaintiff: Date:
ZNAA LL WHS
LLL i
IRELATED ACTIONS: Please provide the case num ejname, “and cou opprany rel lated action: pgnding the Superior ‘Cour
CERTIFICATION PURSUANT TO SJC RULE 1:18
| hereby certify that | have complied with requirements of Rule 5 of the Supreme Judicial Court Uniform Rules on Dispute Resolution (SUC
Rule 1:18) requiring that | provide my clients with information about court-connected dispufe resolution services and discuss with them the
advantages and disadvantages of the various methods of dispute resolution.
.
Signature of Attorney of Record: X' nusoocl bag bate: /2[)3]a0-
J
CIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
AG Actions Involving the State/Municipality * ER Equitable Remedies RP
Property
Real
AAI Contract Action involving Commonwealth, 01 Specific Performance
of a Contract “ 01 Land Taking (FY
Municipality, MBTA, etc, Doz Reach and Apply G02 Zoning Appeal, G.L. ¢. 408 ()
‘ABI Tortious Action involving Commanweatth, DOs Injunction «F) C03 Dispute Concerning Tite )
Municipality, MBTA, etc. 004 Reform/ Cancel Instrument Ce4 Foreclosure of a Mortgage
AGI Real Property Action involving DOS Equitable Replevin ) ‘COS Condominium Lien & Charges
‘Commonwealth, Municipality, MBTA ete. (A) D06 Centribution or Indemnification ) C89 Oiher Real Property Action ®)
AD1 Equity Action invalving Commonweatth, 07 Imposition of a Trust
Municipality, MBTA, etc. 008 Minerity Shareholder’s Suit (A) -MG
Miscellaneous
Civil Actions
AE1 Administrative Action involving 008 Interference in Contractual Relationship (F)
Commonwealth, Municipality, MBTA,etc. (A) Di0 Accounting E18 Foreign Discovery Proceeding «
11 Enforcement of Restrictive Covenant E97 Prisoner Habeas Corpus
CN Contract/Business Cases D12
D13
Dissolution of a Partnership
Declaratory Judgment, G.L.¢.231A
)
) 222 Lottery Assignment, G.L. c. 10 §28
.
8
AO4 Services, Labor, and Materials © D14 Dissolution of a Corporation ®) B Abuse/Haras
A02 Goods Sold and Delivered © Ds Other Equity Action ©
‘A03 Commercial Paper © E15 Abuse Prevention Pefition, G.L.c. 208A (X)
‘A04 Employment Contract PA Civil Actions Involving Incarcerated Party T E21 Protection from Harassment, G.L. c. 258E(X)
AOS Consumer Revolving Credit- macro ©
AOE Insurance Contract
A0B Sale or Leaseof Real Estate ‘F) PA Contract Action involving an
A12 Construction Dispute A Incarcerated Party A) 02 Appeal frem Administrative Agency,
At4 Interpleader (F)
PB1 Tortious Action involving an GLc. 304
BAi Governance, Conduct, Intemal Incarcerated Party a E03 Certiorari Action, G.L. c.249 §4
Affairs of Entities PG1 Real Property Action involving an ”
a Incarcerated Party E05 Confirmation of Arbitration Awards o
BAG Liability of Shareholders, Directors, © E05 Mass Antitrust Act, G. Lc. 93 §9 (A)
Officers, Partners, etc, A) PD1 Equity Action involving an E07 Mass Antitrust Act, G. L. c. 93 §8
BB Shareholder Derivative Incarcerated Party ® ©
(A) PE1 Administrative Action involving an E08 Appointment of a Receiver ®)
BB? Securities Transactions E03 Construction Surety Bond, G.L. ¢, 149
8Ct Mergers, Consolidations, Sales of Incarcerated Party ) §§29, 298
Assets, Issuance ef Debt, Equity, etc. )
(a) E10 Summary Process Appeal ”
8D1 Inteitectual Property (A) RTorts E11 Worker's Compensation ”
D2 Proprietary Information or Trade E16 Auto Surcharge Appeal
Secrets “a 803 Motor Vehicle Negligence - Personal E17 Civil Rights Act, GL. ¢.12 §1 1H,
BG1 Financial Instituions/Funds @ Injury’Propery Damage E24 Appeal from District Court
A)
BH1 Violation of Antitrust or Trade B04 Other Negligence - Personal Commitment, G.L. 6.125 §9(b)
Regtlation Laws ¢ InjuryfProperty Damage ) E25 Pleural Registry (Asbestos cases)
A9S Other Contract/Business Action - Specify (F) BOS Products Liability A) E95 Forfeiture, G.L. ¢.94C §47
BOS Malpractice - Medical ©
BO7 Malpractice - Other £99 Other Administrative Action
“A 201 Medical Malpractice - Tribunal only,
* Choose this case type if ANY party is the B08 Wrongful Death - Non-medical G.L c. 234 §60B
Commonweaith, a municipality, the MBTA, or any B18 Defamation A) ©
ether governmental entity UNLESS your case 's 3 B19 Asbestos 202 Appeal Bond Denial
“a
case type listed under Administrative Civil Actions £20 Personal Injury - Slip & Fall ) ‘SO Sex Offender Review
A). B21 Envirani
B22 Employment Discrimination (Fy 12 SDP Commitment, G.L. c. 123A §12
+t Choose this case type if ANY party is an BE1 Fraud, Business Torts, etc. £14 SDP Peiition, G.L, . 123A §9(b)
)
incarcerated parly, UNLESS your case is a case B99 Other Tortious Action ©) ©
type tisted under Administrative Civil Acfions (AA) BE Restricted Civil Actions
or is a Prisoner Habeas Corpus case (E87). RP Summary Process (Real Property)
S01 Summary Process - Residential E19 Sex Offender Registry, G.L.c.6§178M (x)
@) E27 Minor Seeking Consent, G.L. 6.112 §12S (x)
$02 Summary Process - Commercial/
Non-residential ©
TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
YES
BOS Motor Vehicle Negligence-Personal Injury
STATEMENT OF DAMAGES PURSUANT TO G.L. c. 212, § 3A
DUTY OF THE PLAINTIFF - The plaintiff shalt set forth, on the face of the civil action cover sheet (or attach additional sheets as necessary), a
‘statement specifying the facts on which the plaintiff relies to determine money damages. A copy af such civil action cover sheet, including the
Statement as to the damages, shall be served with the complaint. A clerk-magistrate shall not accept for filing a complaint, except as
otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or self-represented litigant.
DUTY OF THE DEFENDANT - If the defendant believes that the statement of damages filed by the plaintiff is inadequate, the defendant may
file with his/her answer a statement specifying the potential damages which may result if the plaintiff prevails.
A CIVIL COVER SHEET MUST BE FILED WITH EACH COMPLAINT,
FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY
MAY RESULT IN DISMISSAL OF THIS ACTION.
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DOCKET NUMBER zz cy Y95~ Trial Court of Massachusetts CIVIL ACTION COVER SHEET PLAINTIFF(S): The Superior Court lcouNTY w/ ADDRESS: Borastabl. DEFENDANT(S): for Es rent oe ATTORNEY: ADDRESS: Sis 3 Klaeriy Poasl D6 Gere Bea We (92.502. BBO: Lets! 64 TYPE OF ACTION AND TRACK DESIGNATION {see reverse side) og cl Accdeons “F CODE NO. TYPE OF Al CcON (specify) lh HAS A JURY CLAIM SEEN MADE? uur To Ous fit ves (1xo “If "Other" please describe: is there a claim under G.L. c. 93A7 Js this a class action ler Mass. R. Civ. P. 237 | YES: NO STATEMENT OF DAMAGES PURSUANT TO GL. c. 212, § 3A {The following is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiffs counsel relies to determine money damages. For this form, disregard double or treble damage claims; indicate single damages only. TORT CLAIMS (attach additional sheets as necessary) ° \A, Documented medical expenses to date: 1. Total hospital expenses: 2. Total doctor expenses 3. Total chiropractic expenses 4. Total physical iherapy expenses 5. Total other expenses (describe below) $5 OOO Subtotal (A): B, Documented lost wages and compensation fo date IC. Documented properly damages to dale . . D. Reasonably anticipated future medical and hospital expense: E. Reasonably anticipated lost wages .. IF. Other documented items of damages (describe below) 6. Briefly describe plaintiff's injury, including the nature and extent of injury: TOTAL (A-FI$ OOOO 5D LAIMS, (attach additional sheets as necessary) This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass. R. Civ. P. 8.1(a). Provide a detailed description af claim(s): TOTAL: $ Signature of Attorney/ Unrepresented Plaintiff: Date: ZNAA LL WHS LLL i IRELATED ACTIONS: Please provide the case num ejname, “and cou opprany rel lated action: pgnding the Superior ‘Cour CERTIFICATION PURSUANT TO SJC RULE 1:18 | hereby certify that | have complied with requirements of Rule 5 of the Supreme Judicial Court Uniform Rules on Dispute Resolution (SUC Rule 1:18) requiring that | provide my clients with information about court-connected dispufe resolution services and discuss with them the advantages and disadvantages of the various methods of dispute resolution. . Signature of Attorney of Record: X' nusoocl bag bate: /2[)3]a0- J CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE AG Actions Involving the State/Municipality * ER Equitable Remedies RP Property Real AAI Contract Action involving Commonwealth, 01 Specific Performance of a Contract “ 01 Land Taking (FY Municipality, MBTA, etc, Doz Reach and Apply G02 Zoning Appeal, G.L. ¢. 408 () ‘ABI Tortious Action involving Commanweatth, DOs Injunction «F) C03 Dispute Concerning Tite ) Municipality, MBTA, etc. 004 Reform/ Cancel Instrument Ce4 Foreclosure of a Mortgage AGI Real Property Action involving DOS Equitable Replevin ) ‘COS Condominium Lien & Charges ‘Commonwealth, Municipality, MBTA ete. (A) D06 Centribution or Indemnification ) C89 Oiher Real Property Action ®) AD1 Equity Action invalving Commonweatth, 07 Imposition of a Trust Municipality, MBTA, etc. 008 Minerity Shareholder’s Suit (A) -MG Miscellaneous Civil Actions AE1 Administrative Action involving 008 Interference in Contractual Relationship (F) Commonwealth, Municipality, MBTA,etc. (A) Di0 Accounting E18 Foreign Discovery Proceeding « 11 Enforcement of Restrictive Covenant E97 Prisoner Habeas Corpus CN Contract/Business Cases D12 D13 Dissolution of a Partnership Declaratory Judgment, G.L.¢.231A ) ) 222 Lottery Assignment, G.L. c. 10 §28 . 8 AO4 Services, Labor, and Materials © D14 Dissolution of a Corporation ®) B Abuse/Haras A02 Goods Sold and Delivered © Ds Other Equity Action © ‘A03 Commercial Paper © E15 Abuse Prevention Pefition, G.L.c. 208A (X) ‘A04 Employment Contract PA Civil Actions Involving Incarcerated Party T E21 Protection from Harassment, G.L. c. 258E(X) AOS Consumer Revolving Credit- macro © AOE Insurance Contract A0B Sale or Leaseof Real Estate ‘F) PA Contract Action involving an A12 Construction Dispute A Incarcerated Party A) 02 Appeal frem Administrative Agency, At4 Interpleader (F) PB1 Tortious Action involving an GLc. 304 BAi Governance, Conduct, Intemal Incarcerated Party a E03 Certiorari Action, G.L. c.249 §4 Affairs of Entities PG1 Real Property Action involving an ” a Incarcerated Party E05 Confirmation of Arbitration Awards o BAG Liability of Shareholders, Directors, © E05 Mass Antitrust Act, G. Lc. 93 §9 (A) Officers, Partners, etc, A) PD1 Equity Action involving an E07 Mass Antitrust Act, G. L. c. 93 §8 BB Shareholder Derivative Incarcerated Party ® © (A) PE1 Administrative Action involving an E08 Appointment of a Receiver ®) BB? Securities Transactions E03 Construction Surety Bond, G.L. ¢, 149 8Ct Mergers, Consolidations, Sales of Incarcerated Party ) §§29, 298 Assets, Issuance ef Debt, Equity, etc. ) (a) E10 Summary Process Appeal ” 8D1 Inteitectual Property (A) RTorts E11 Worker's Compensation ” D2 Proprietary Information or Trade E16 Auto Surcharge Appeal Secrets “a 803 Motor Vehicle Negligence - Personal E17 Civil Rights Act, GL. ¢.12 §1 1H, BG1 Financial Instituions/Funds @ Injury’Propery Damage E24 Appeal from District Court A) BH1 Violation of Antitrust or Trade B04 Other Negligence - Personal Commitment, G.L. 6.125 §9(b) Regtlation Laws ¢ InjuryfProperty Damage ) E25 Pleural Registry (Asbestos cases) A9S Other Contract/Business Action - Specify (F) BOS Products Liability A) E95 Forfeiture, G.L. ¢.94C §47 BOS Malpractice - Medical © BO7 Malpractice - Other £99 Other Administrative Action “A 201 Medical Malpractice - Tribunal only, * Choose this case type if ANY party is the B08 Wrongful Death - Non-medical G.L c. 234 §60B Commonweaith, a municipality, the MBTA, or any B18 Defamation A) © ether governmental entity UNLESS your case 's 3 B19 Asbestos 202 Appeal Bond Denial “a case type listed under Administrative Civil Actions £20 Personal Injury - Slip & Fall ) ‘SO Sex Offender Review A). B21 Envirani B22 Employment Discrimination (Fy 12 SDP Commitment, G.L. c. 123A §12 +t Choose this case type if ANY party is an BE1 Fraud, Business Torts, etc. £14 SDP Peiition, G.L, . 123A §9(b) ) incarcerated parly, UNLESS your case is a case B99 Other Tortious Action ©) © type tisted under Administrative Civil Acfions (AA) BE Restricted Civil Actions or is a Prisoner Habeas Corpus case (E87). RP Summary Process (Real Property) S01 Summary Process - Residential E19 Sex Offender Registry, G.L.c.6§178M (x) @) E27 Minor Seeking Consent, G.L. 6.112 §12S (x) $02 Summary Process - Commercial/ Non-residential © TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? YES BOS Motor Vehicle Negligence-Personal Injury STATEMENT OF DAMAGES PURSUANT TO G.L. c. 212, § 3A DUTY OF THE PLAINTIFF - The plaintiff shalt set forth, on the face of the civil action cover sheet (or attach additional sheets as necessary), a ‘statement specifying the facts on which the plaintiff relies to determine money damages. A copy af such civil action cover sheet, including the Statement as to the damages, shall be served with the complaint. A clerk-magistrate shall not accept for filing a complaint, except as otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or self-represented litigant. DUTY OF THE DEFENDANT - If the defendant believes that the statement of damages filed by the plaintiff is inadequate, the defendant may file with his/her answer a statement specifying the potential damages which may result if the plaintiff prevails. A CIVIL COVER SHEET MUST BE FILED WITH EACH COMPLAINT, FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY MAY RESULT IN DISMISSAL OF THIS ACTION.