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HL
AMENDED
DOCKET NUMBER Trial Court of Massachusetts
CIVIL ACTION COVER SHEET 2173CV00627 The Superior Court
{COUNTY [Bristol Superior Court (New Bedford)
Plaintiff James Jones Defendant: Shane Poitras
ADDRESS: One State Street ADDRESS: 232 Caroline Street
Suite 750 BRISTOL. SS SUPERIOR CC NaiiBedford, MA 02740
Boston, MA 02109 FILED
Plaintiff Attorney: RyanD. Lang i1 A 9094
orp Defendant Attorney:
‘ADDRESS: One State Street vtt at ‘ADDRESS:
Suite 750
WARC I SANTOS eSU
Boston MA, 02109 CLERKIMA 1:
MAGISTRATE BBO:
580: 708051
TYPE OF ACTION AND TRACK DESIGNATION (see instructions section below)
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
BOo3 Motor Vehicle Negligence - Personal Injury F I] Yes 1 No
*If "Other" please descri
Is there a claim under G.L. c. 93A? \s there a class action under Mass. R. Civ. P. 23?
Oyes XK no (yes I no
STATEMENT OF DAMAGES PURSUANT TO G.L. 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 damage:
For this form, disregard double or treble damage claims; indicate single damages only.
TORT CLAIMS
|A. Documented medical expenses to date
1. Total hospital expenses TBD
2. Total doctor expenses TBD
3, Total chiropractic expenses TBD
4. Total physical therapy expenses TBD
5. Total other expenses (describe below) > $50,000.00
Pain and Suffering
Subtotal (1-5): > $50,000.00
B. Documented lost wages and compensation to date
C. Documented property damages to date
D. Reasonably anticipated future medical and hospital expenses
E. Reasonably anticipated lost wages
F. Other documented items of damages (describe below)
| TOTAL (A-F): >_ $50,000.00
G. Briefly describe plaintiff's injury, including the nature and extent of injury:
[ Including but not limited to neck and back injuries.
CONTRACT CLAIMS
1 This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass. R. Civ. P. 8.1(a).
tem # Detailed Description of Each Claim Amount
1
Total
Signature of Attomey/Unrepresented Plaintiff: X 8 | FZ 21 ]
RELATED ACTIONS: Please provide the case number, case name, and county of any related actions pending in the Superior Court.
CERTIFICATION PURSUANT TO SJC RULE 1:18
Thereby cerfy that | have complied with requirements of Rule 5 of the Supreme Judicia| Court Uniform Rules on Dispute Resolution (SJC Rule 1:18) requiring that | provide my
clients with information about court-connected dispute resolution services. ith she-edvantages
them and disadvantages ofthe various methods of dispute,
| [_ ate: 4/47 ai T1
=
‘Signature of Attorney/Unrepresented Plaintiff: X = =
‘$C0001: 1/22/2021 ‘www.mass.govl ims Date/Time Printed:09-09-2021 10:13:24
|
i
CIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
A ving the Munici ER Equitable Remedies RP Real
‘AA Contract Action involving Commonwealth, 01 Specific Performance of a Contract (A) C01 Land Taking ©)
Municipality, MBTA, etc. D02 Reach and Apply (F) C02 Zoning Appeal, G.L. c: 408 ©)
AB1 Tortious Action involving Commonwealth, 1DO3 Injunction ©) C03 Dispute Concerning Title ©)
Municipality, MBTA, etc. (A) 04 Reform/ Cancel Instrument C04 Foreclosure of a Mortgage &)
‘AC1 Real Property Action involving DOS Equitable Replevin ) C05 Condominium Lien & Charges
Commonwealth, Municipality, MBTA etc. (A) 06 Contribution or Indemnification (F) (C99 Other Real Property Action ©)
AD1 Equity Action involving Commonwealth, 1DO7 Imposition of a Trust (A)
Municipality, MBTA, etc. @) 08 Minority Shareholder's Suit (A) Civil Action:
‘AE1 Administrative Action involvin 109 Interference in Contractuat Relationship )
‘Commonwealth, Municipality, MBTA,etc. (A) 10 Accounting 18 Foreign Discovery Proceeding e
D114 Enforcement of Restrictive Covenant © E97 Prisoner Habeas Corpus &)
CN Contract/Business Cases D12 Dissolution of a Partnership (F) E22 Lottery Assignment, G.L. c. 10, § 28 ®)
D13 Declaratory Judgment, G.L. c. 2314 (A)
‘A01 Services, Labor, and Materials 14 Dissolution of a Corporation B Abuse/Harassment Prevention.
‘A02 Goods Sold and Delivered © 99 Other Equity Action )
‘A03 Commercial Paper F) E15 Abuse Prevention Petition, G.L. c. 209A _(X)
‘A04 Employment Contract F) PA Civil Actions Involving Incarcerated
Party t E21 Protection from Harassment, G.L. c. 258E(X)
‘A05 Consumer Revolving Credit - urce.e1 fy
‘AQ6 Insurance Contract ©) AA
Administrative
Civil Actions
A08 Sale or Lease of Real Estate (F) PA1 Contract Action involving an
‘A12 Construction Dispute (a) Incarcerated Party @ E02 Appeal from Administrative Agency,
14 Interpleader (F) PB1 Tortious Action involving an Lc. 31 ®
BA Govemance, Conduct, Internal Incarcerated Part @) E03 Certiorari Action, G.L. c. 249, § 4 ®),
Affairs of Entities @) C1 Real Property Action involving an E05 Confirmation of Arbitration Awards ®
BA3 Liability of Shareholders, Directors, Incarcerated Party ) E06 Mass Antitrust Act, G.L.c. 93, § 9 @
Officers, Partners, etc. (a) PD1 Equity Action involving an E07 Mass Antitrust Act, G.L.c. 93, § 8 ®)
BB1 Shareholder Derivative (A) Incarcerated Party ) E08 Appointment of a Receiver ®)
BB2 Securities Transactions (A) PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. c. 149,
BC1 Mergers, Consolidations, Sales of Incarcerated Party F) §§ 29, 298 (A)
Assets, [ssuance of Debt, Equity, etc. a) £10 Summary Process Appeal ®
BD1 Intellectual Property (A) IRTorts. E11 Worker's Compensation &)
8D2 Proprietary Information or Trade E16 Auto Surcharge Appeal ®)
Secrets (A) B03 Motor Vehicle Negligence - Personal E17 Civil Rights Act, G.L. c.12, § 11H a)
G1 Financial Institutions/Funds. a) Injury’Properly Damage (F) E24 Appeal from District Court
BH1 Violation of Antitrust or Trade B04 Other Negligence - Personal Commitment, G.L. ¢.123, § 9(b) )
Regulation Laws Injury/Property Damage ©) E25 Pleural Registry (Asbestos cases)
‘A99 Other Contract/Business Action - Specify 6 B05 Products Liability (A) E94 Forfeiture, G.L. c. 265, § 56 ®)
B06 Malpractice - Medical (A) E95 Forfeiture, G.L. c. 94C, § 47 )
B07 Malpractice - Other (A) £99 Other Administrative Action &)
* Choose this case type if ANY party is the B08 Wrongful Death - Non-medical (A) 201 Medical Malpractice - Tribunal only,
Commonwealth, a municipality, the MBTA, or any B15 Defamation (A) G.L.c. 231, § 60B )
other governmental entity UNLESS your case is a B19 Asbestos a) Z02 Appeal Bond Denial ®)
case type listed under Administrative Civil Actions 20 Personal Injury - Slip & Fall (F)
(AA), B21 Environmental (F) SO Sex Offender Review
‘+t Choose this case type if ANY party is an B22 Employment Discrimination (F)
BE1 Fraud, Business Torts, etc. (A) E12 SDP Commitment, G.L. c. 123A, § 12 ®
incarcerated party, UNLESS your case is a case B99 Other Tortious Action F) E14 SDP Petition, G.L. c. 123A, § 9(b) ®)
type listed under Administrative Civil Actions (AA)
or is a Prisoner Habeas Corpus case (E97). RP Summary Process (Real Property) RC
Restricted
Civil Actions
‘$01 Summary Process - Residential ” E19 Sex Offender Registry, G.L.c. 6, § 178M (x)
‘$02 Summary Process - Commercial! E27 Minor Seeking Consent, 6.112, § 128(X)
Non-residential F
TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
[xX] YES
B03 Motor Vehicle Negligence-Personal Injury
STATEMENT OF DAMAGES PURSUANT TO GL. c. 212, § 3A
DUTY OF THE PLAINTIFF - The plaintiff shall 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 of 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, xcept 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. :
ACIVIL COVER SHEET MUST BE FILED WITH EACH COMPLAINT.
FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY
MAY RESULT IN DISMISSAL OF THIS ACTION.
C0001: 1/22/2021 www.mass.gov/courts Date/Time Printed:09-09-2021 10:13:24
Preview
HL AMENDED DOCKET NUMBER Trial Court of Massachusetts CIVIL ACTION COVER SHEET 2173CV00627 The Superior Court {COUNTY [Bristol Superior Court (New Bedford) Plaintiff James Jones Defendant: Shane Poitras ADDRESS: One State Street ADDRESS: 232 Caroline Street Suite 750 BRISTOL. SS SUPERIOR CC NaiiBedford, MA 02740 Boston, MA 02109 FILED Plaintiff Attorney: RyanD. Lang i1 A 9094 orp Defendant Attorney: ‘ADDRESS: One State Street vtt at ‘ADDRESS: Suite 750 WARC I SANTOS eSU Boston MA, 02109 CLERKIMA 1: MAGISTRATE BBO: 580: 708051 TYPE OF ACTION AND TRACK DESIGNATION (see instructions section below) CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? BOo3 Motor Vehicle Negligence - Personal Injury F I] Yes 1 No *If "Other" please descri Is there a claim under G.L. c. 93A? \s there a class action under Mass. R. Civ. P. 23? Oyes XK no (yes I no STATEMENT OF DAMAGES PURSUANT TO G.L. 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 damage: For this form, disregard double or treble damage claims; indicate single damages only. TORT CLAIMS |A. Documented medical expenses to date 1. Total hospital expenses TBD 2. Total doctor expenses TBD 3, Total chiropractic expenses TBD 4. Total physical therapy expenses TBD 5. Total other expenses (describe below) > $50,000.00 Pain and Suffering Subtotal (1-5): > $50,000.00 B. Documented lost wages and compensation to date C. Documented property damages to date D. Reasonably anticipated future medical and hospital expenses E. Reasonably anticipated lost wages F. Other documented items of damages (describe below) | TOTAL (A-F): >_ $50,000.00 G. Briefly describe plaintiff's injury, including the nature and extent of injury: [ Including but not limited to neck and back injuries. CONTRACT CLAIMS 1 This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass. R. Civ. P. 8.1(a). tem # Detailed Description of Each Claim Amount 1 Total Signature of Attomey/Unrepresented Plaintiff: X 8 | FZ 21 ] RELATED ACTIONS: Please provide the case number, case name, and county of any related actions pending in the Superior Court. CERTIFICATION PURSUANT TO SJC RULE 1:18 Thereby cerfy that | have complied with requirements of Rule 5 of the Supreme Judicia| Court Uniform Rules on Dispute Resolution (SJC Rule 1:18) requiring that | provide my clients with information about court-connected dispute resolution services. ith she-edvantages them and disadvantages ofthe various methods of dispute, | [_ ate: 4/47 ai T1 = ‘Signature of Attorney/Unrepresented Plaintiff: X = = ‘$C0001: 1/22/2021 ‘www.mass.govl ims Date/Time Printed:09-09-2021 10:13:24 | i CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE A ving the Munici ER Equitable Remedies RP Real ‘AA Contract Action involving Commonwealth, 01 Specific Performance of a Contract (A) C01 Land Taking ©) Municipality, MBTA, etc. D02 Reach and Apply (F) C02 Zoning Appeal, G.L. c: 408 ©) AB1 Tortious Action involving Commonwealth, 1DO3 Injunction ©) C03 Dispute Concerning Title ©) Municipality, MBTA, etc. (A) 04 Reform/ Cancel Instrument C04 Foreclosure of a Mortgage &) ‘AC1 Real Property Action involving DOS Equitable Replevin ) C05 Condominium Lien & Charges Commonwealth, Municipality, MBTA etc. (A) 06 Contribution or Indemnification (F) (C99 Other Real Property Action ©) AD1 Equity Action involving Commonwealth, 1DO7 Imposition of a Trust (A) Municipality, MBTA, etc. @) 08 Minority Shareholder's Suit (A) Civil Action: ‘AE1 Administrative Action involvin 109 Interference in Contractuat Relationship ) ‘Commonwealth, Municipality, MBTA,etc. (A) 10 Accounting 18 Foreign Discovery Proceeding e D114 Enforcement of Restrictive Covenant © E97 Prisoner Habeas Corpus &) CN Contract/Business Cases D12 Dissolution of a Partnership (F) E22 Lottery Assignment, G.L. c. 10, § 28 ®) D13 Declaratory Judgment, G.L. c. 2314 (A) ‘A01 Services, Labor, and Materials 14 Dissolution of a Corporation B Abuse/Harassment Prevention. ‘A02 Goods Sold and Delivered © 99 Other Equity Action ) ‘A03 Commercial Paper F) E15 Abuse Prevention Petition, G.L. c. 209A _(X) ‘A04 Employment Contract F) PA Civil Actions Involving Incarcerated Party t E21 Protection from Harassment, G.L. c. 258E(X) ‘A05 Consumer Revolving Credit - urce.e1 fy ‘AQ6 Insurance Contract ©) AA Administrative Civil Actions A08 Sale or Lease of Real Estate (F) PA1 Contract Action involving an ‘A12 Construction Dispute (a) Incarcerated Party @ E02 Appeal from Administrative Agency, 14 Interpleader (F) PB1 Tortious Action involving an Lc. 31 ® BA Govemance, Conduct, Internal Incarcerated Part @) E03 Certiorari Action, G.L. c. 249, § 4 ®), Affairs of Entities @) C1 Real Property Action involving an E05 Confirmation of Arbitration Awards ® BA3 Liability of Shareholders, Directors, Incarcerated Party ) E06 Mass Antitrust Act, G.L.c. 93, § 9 @ Officers, Partners, etc. (a) PD1 Equity Action involving an E07 Mass Antitrust Act, G.L.c. 93, § 8 ®) BB1 Shareholder Derivative (A) Incarcerated Party ) E08 Appointment of a Receiver ®) BB2 Securities Transactions (A) PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. c. 149, BC1 Mergers, Consolidations, Sales of Incarcerated Party F) §§ 29, 298 (A) Assets, [ssuance of Debt, Equity, etc. a) £10 Summary Process Appeal ® BD1 Intellectual Property (A) IRTorts. E11 Worker's Compensation &) 8D2 Proprietary Information or Trade E16 Auto Surcharge Appeal ®) Secrets (A) B03 Motor Vehicle Negligence - Personal E17 Civil Rights Act, G.L. c.12, § 11H a) G1 Financial Institutions/Funds. a) Injury’Properly Damage (F) E24 Appeal from District Court BH1 Violation of Antitrust or Trade B04 Other Negligence - Personal Commitment, G.L. ¢.123, § 9(b) ) Regulation Laws Injury/Property Damage ©) E25 Pleural Registry (Asbestos cases) ‘A99 Other Contract/Business Action - Specify 6 B05 Products Liability (A) E94 Forfeiture, G.L. c. 265, § 56 ®) B06 Malpractice - Medical (A) E95 Forfeiture, G.L. c. 94C, § 47 ) B07 Malpractice - Other (A) £99 Other Administrative Action &) * Choose this case type if ANY party is the B08 Wrongful Death - Non-medical (A) 201 Medical Malpractice - Tribunal only, Commonwealth, a municipality, the MBTA, or any B15 Defamation (A) G.L.c. 231, § 60B ) other governmental entity UNLESS your case is a B19 Asbestos a) Z02 Appeal Bond Denial ®) case type listed under Administrative Civil Actions 20 Personal Injury - Slip & Fall (F) (AA), B21 Environmental (F) SO Sex Offender Review ‘+t Choose this case type if ANY party is an B22 Employment Discrimination (F) BE1 Fraud, Business Torts, etc. (A) E12 SDP Commitment, G.L. c. 123A, § 12 ® incarcerated party, UNLESS your case is a case B99 Other Tortious Action F) E14 SDP Petition, G.L. c. 123A, § 9(b) ®) type listed under Administrative Civil Actions (AA) or is a Prisoner Habeas Corpus case (E97). RP Summary Process (Real Property) RC Restricted Civil Actions ‘$01 Summary Process - Residential ” E19 Sex Offender Registry, G.L.c. 6, § 178M (x) ‘$02 Summary Process - Commercial! E27 Minor Seeking Consent, 6.112, § 128(X) Non-residential F TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? [xX] YES B03 Motor Vehicle Negligence-Personal Injury STATEMENT OF DAMAGES PURSUANT TO GL. c. 212, § 3A DUTY OF THE PLAINTIFF - The plaintiff shall 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 of 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, xcept 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. : ACIVIL COVER SHEET MUST BE FILED WITH EACH COMPLAINT. FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY MAY RESULT IN DISMISSAL OF THIS ACTION. C0001: 1/22/2021 www.mass.gov/courts Date/Time Printed:09-09-2021 10:13:24