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DOCKET NUMBER Trial Court of Massachusetts
CIVIL ACTION COVER SHEET
The Superior Court
FY CVOTEX
PLAINTIFF(S): Ohyoad A Siunvkba JCOUNTY
ADDRESS: 69 Luca pilts. kd
3e yy DEFENDANTS: Gommmon Wealty, OF Macs Division F lsumse
CIT L6G A312 Bewd Of APPeu)
ATTORNEY: te Cem 1
ADDRESS: ADDRESS: 1060 la Shiva tora treet
.
an Loe
BBO:
TYPE OF ACTION AND TRACK DESIGNATION (see reverse side)
CODE NO. TYPE OF ACTION (specify) HAS A JURY CLAIM BEEN MADE?
C {5 OC Yes 0 no
“If "Other" please describe:
Is there a claim under G.L. c. 93A7 fs this a class action under Nass. R. Civ. P, 237
STATEMENT OF DAMAGES PURSUANT TO G.L. c. 212, § 3A
The foltowing is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiff's counsel relies to determine money damages.
For this form, disregard double or treble damage claims; indicate single damages only.
(attach additional sheets as necessary)
|A. Documented medical expenses to date: —————
1. Total hospital expenses
1
2. Total doctor expenses GEORTHE:
3. Total chiropractic expenses CLERK. COUR
4. Total physical therapy expenses
6. Total other expenses (describe below)
MAR 1 & 2024 ‘Subtotal (A)
B. Documented lost wages and compensation to date
\C. Documented property damages to date oF vag
D. Reasonably anticipated future medical and hospital expenses seat
|. Reasonably anticipated lost wages Fp
IF. Other documented items of damages (describe below)
|G. Briefly describe plaintiffs injury, including the nature and extent of injury:
TOTAL (A-F):$
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 of claim(s):
TOTAL: $
Signature of Attorney/ Unrepresented Plaintiff: X Date:
IRELATED 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
| 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 dispute resolution services and discuss with them the
advantages and disadvantages of the vari
Signature of Attorney of Record: pate: 3/14 [2024
CIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
AG Actions Involving the State/Municipality * ER Equitable Remedies. RP Real Property
AAT Contract Action Involving Commonwealth, 001 Specific Performance of a Contract a) C01 Land Taking )
Municipality, MBTA, etc. A) 002 Reach and Apply C02 Zoning Appeal, G.L.c. 404. (F)
AB1 Tortious Action involving Commonwealth, 1003 Injunction ) C03 Dispute Concerning Title ()
Municipality, MBTA, etc. @) D04 Reform/ Cancel Instrument ) (C04 Foreclosure of a Mortgage )
AC Real Property Action involving DOS Equitable Replevin © COS Condominium Lien & Charges o
‘Commonwealth, Municipality, MBTA etc. (A) 06 Contribution or Indemnification ) C99 Other Real Property Action «)
AD1 Equity Action involving Commonwealth, 07 Imposition of a Trust (A)
Municipality, MBTA, etc, 08 Minority Shareholder’s Suit (A) -MC
Miscellaneous
2 Civil Actions
AE1 Administiative Action involving ‘D09 Interference in Contractual Relationship
Commonwealth, Municipality, MBTA,etc. (A) Dt0 Accounting E18 Foreign Discovery Proceeding ®)
D141 Enforcementof Restrictive Covenant (F) E97 Prisoner Habeas Corpus
CN
Contract/Business
Cases 12 Dissolution of a Partnership F) 22 Lottery Assignment, G.L. ¢. 10 §28 ”)
D13 Declaratory Judgment, G.L. c.231A. (A)
A01 Services, Labor, and Materials D14 Dissolution of a Corporation AB Abuse/Harassment Prevention.
‘A02 Goods Sold and Delivered «) D99 Other Equity Action )
A03 Commercial Paper ) E15 Abuse Prevention Petition, G.L. c. 209A (X)
‘A04 Employment Contract ) E21 Protection from Harassment, .¢, 258E(X)
PA Givil Actions Involving Incarcerated
Party t
‘AOS Consumer Revolving Credit - ma.cP. a ) -AA
Administrative
Civil Actions,
‘A06 Insurance Contract PA Contract Action involving an
A08 Sale or Lease of Real Estate (F) Incarcerated Party ) 02 Appeal from Administrative Agency,
A12 Construction Dispute (A) PBI Tortious Action involving an
A14 Interpleader (F) GL.c.
Incarcerated £03 Certiorari Action, G.L, ¢.249 §4 ®)
BA1 Governance, Conduct, Internal PC1 Real Property Action involving an E05 Confirmation of Arbitration Awards: ”
Affairs of Entities A Incarcerated Party E06 Mass Antitrust Act, G. L. c. 93 §9 A)
BA3 Liability of Shareholders, Directors, PD1 Equity Action involving an E07 Mass Antitrust Act, G. L.c. 93 §8
Officers, Partners, etc, @) Incarcerated Pai (F) £08 Appointment of a Receiver ®)
BB1 Shareholder Derivative PE1 Administrative Action involving an £09 Construction Surety Bond, G.L. c. 149
BB2 Securities Tranisactions A) Incarcerated Party ) §§29, 294 (A)
8C1 Mergers, Consolidations, Sales of
Assets, Issuance of Debt, Equity, etc. @ £40 Summary Process Appeal ®
BD1 Intellectual Property (A)
IR Torts £11 Worker's Compensation ®)
B02 Proprietary Information or Trade E16 Auto Surcharge Appeal ”)
B03 Motor Vehicle Negligence - Personal E47 Civil Rights Act, G.L. ¢.12 §t1H (A)
Secrets A) Injury/Property Damage ) E24 Appeal from District Court
8G1 Financial Institutions/Funds @) B04 Other Negligence - Personal Commitment, G.L. ¢.123 §9(b) ”)
BH1 Violation of Antitrust or Trade Injury/Property: Damage F) £25 Pleural Registry (Asbestos cases)
Regulation Laws (A) 805 Products Liability (a)
‘A99 Other Contract/Business Action - Specify (F) E96 Forfeiture, G.L. 0.940. $47 (F)
B06 Malpractice - Medical E99 Other Administrative Action ”
B07 Malpractice - Other (A) 201 Medical Malpractice ~ Tribunal only,
* Choose this case type if ANY party is the 808 Wrongful Death - Non-medical A) GL. c. 231 §60B ®)
‘Commonwealth, a municipality, the MBTA, or any 815 Defamation (A) Z02 Appeal Bond Denial ”)
other governmental entity UNLESS your case is a B19 Asbestos @)
case type listed under Administrative Civil Actions. B20 Personal injury - Slip & Fall (FY ‘SO Sex Offender Review
(AA). 821 Environmental «)
822 Employment Discrimination (F) E12 SDP Commitment, G.L. ¢. 1234 §12 ~
+ Choose this case type if ANY party is an BE1 Fraud, Business Torts, etc. 44 SDP Petition, G.L. c. 123A §9(b) ”
incarcerated party, UNLESS your case is a case B99 Other Tortious Action )
type listed under Administrative Civil Actions (AA) RGRestricted
Civil Actions
oris a Prisoner Habeas Corpus case (E97). RP.Summary
Process (Real Property}
E19 Sex Offender Registry, G.L..6 §178M _ (X)
801 Summary Process - Residential ®) E27 Minor Seeking Consent, G.L. €.112 §128 (X)
$02 Summary Process - Commercial!
Non-residential )
"RANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
YES NO
BOs Motor Vehicle Negligence-Personal Injury —E.
STATEMENT OF DAMAGES PURSUANT TO G.L. c. 212, §3A
as necessary), a
DUTY OF THE PLAINTIFF - The plaintiff shall set forth, on the face of the civil action cover sheet (or attach additional sheets
the
statement specifying the facts on which the plaintiff relies to determine money damages. A copy of such civil action cover sheet, including
clerk-magistrat e shall not accept for filing a complaint, except as.
statement as to the damages, shall be served with the complaint. A
ted litigant.
otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or self-represen
may
DUTY OF THE DEFENDANT - If the defendant believes that the statement of damages filed by the plaintiff is inadequate, the defendant
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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A> DOCKET NUMBER Trial Court of Massachusetts CIVIL ACTION COVER SHEET The Superior Court FY CVOTEX PLAINTIFF(S): Ohyoad A Siunvkba JCOUNTY ADDRESS: 69 Luca pilts. kd 3e yy DEFENDANTS: Gommmon Wealty, OF Macs Division F lsumse CIT L6G A312 Bewd Of APPeu) ATTORNEY: te Cem 1 ADDRESS: ADDRESS: 1060 la Shiva tora treet . an Loe BBO: TYPE OF ACTION AND TRACK DESIGNATION (see reverse side) CODE NO. TYPE OF ACTION (specify) HAS A JURY CLAIM BEEN MADE? C {5 OC Yes 0 no “If "Other" please describe: Is there a claim under G.L. c. 93A7 fs this a class action under Nass. R. Civ. P, 237 STATEMENT OF DAMAGES PURSUANT TO G.L. c. 212, § 3A The foltowing is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiff's counsel relies to determine money damages. For this form, disregard double or treble damage claims; indicate single damages only. (attach additional sheets as necessary) |A. Documented medical expenses to date: ————— 1. Total hospital expenses 1 2. Total doctor expenses GEORTHE: 3. Total chiropractic expenses CLERK. COUR 4. Total physical therapy expenses 6. Total other expenses (describe below) MAR 1 & 2024 ‘Subtotal (A) B. Documented lost wages and compensation to date \C. Documented property damages to date oF vag D. Reasonably anticipated future medical and hospital expenses seat |. Reasonably anticipated lost wages Fp IF. Other documented items of damages (describe below) |G. Briefly describe plaintiffs injury, including the nature and extent of injury: TOTAL (A-F):$ 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 of claim(s): TOTAL: $ Signature of Attorney/ Unrepresented Plaintiff: X Date: IRELATED 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 | 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 dispute resolution services and discuss with them the advantages and disadvantages of the vari Signature of Attorney of Record: pate: 3/14 [2024 CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE AG Actions Involving the State/Municipality * ER Equitable Remedies. RP Real Property AAT Contract Action Involving Commonwealth, 001 Specific Performance of a Contract a) C01 Land Taking ) Municipality, MBTA, etc. A) 002 Reach and Apply C02 Zoning Appeal, G.L.c. 404. (F) AB1 Tortious Action involving Commonwealth, 1003 Injunction ) C03 Dispute Concerning Title () Municipality, MBTA, etc. @) D04 Reform/ Cancel Instrument ) (C04 Foreclosure of a Mortgage ) AC Real Property Action involving DOS Equitable Replevin © COS Condominium Lien & Charges o ‘Commonwealth, Municipality, MBTA etc. (A) 06 Contribution or Indemnification ) C99 Other Real Property Action «) AD1 Equity Action involving Commonwealth, 07 Imposition of a Trust (A) Municipality, MBTA, etc, 08 Minority Shareholder’s Suit (A) -MC Miscellaneous 2 Civil Actions AE1 Administiative Action involving ‘D09 Interference in Contractual Relationship Commonwealth, Municipality, MBTA,etc. (A) Dt0 Accounting E18 Foreign Discovery Proceeding ®) D141 Enforcementof Restrictive Covenant (F) E97 Prisoner Habeas Corpus CN Contract/Business Cases 12 Dissolution of a Partnership F) 22 Lottery Assignment, G.L. ¢. 10 §28 ”) D13 Declaratory Judgment, G.L. c.231A. (A) A01 Services, Labor, and Materials D14 Dissolution of a Corporation AB Abuse/Harassment Prevention. ‘A02 Goods Sold and Delivered «) D99 Other Equity Action ) A03 Commercial Paper ) E15 Abuse Prevention Petition, G.L. c. 209A (X) ‘A04 Employment Contract ) E21 Protection from Harassment, .¢, 258E(X) PA Givil Actions Involving Incarcerated Party t ‘AOS Consumer Revolving Credit - ma.cP. a ) -AA Administrative Civil Actions, ‘A06 Insurance Contract PA Contract Action involving an A08 Sale or Lease of Real Estate (F) Incarcerated Party ) 02 Appeal from Administrative Agency, A12 Construction Dispute (A) PBI Tortious Action involving an A14 Interpleader (F) GL.c. Incarcerated £03 Certiorari Action, G.L, ¢.249 §4 ®) BA1 Governance, Conduct, Internal PC1 Real Property Action involving an E05 Confirmation of Arbitration Awards: ” Affairs of Entities A Incarcerated Party E06 Mass Antitrust Act, G. L. c. 93 §9 A) BA3 Liability of Shareholders, Directors, PD1 Equity Action involving an E07 Mass Antitrust Act, G. L.c. 93 §8 Officers, Partners, etc, @) Incarcerated Pai (F) £08 Appointment of a Receiver ®) BB1 Shareholder Derivative PE1 Administrative Action involving an £09 Construction Surety Bond, G.L. c. 149 BB2 Securities Tranisactions A) Incarcerated Party ) §§29, 294 (A) 8C1 Mergers, Consolidations, Sales of Assets, Issuance of Debt, Equity, etc. @ £40 Summary Process Appeal ® BD1 Intellectual Property (A) IR Torts £11 Worker's Compensation ®) B02 Proprietary Information or Trade E16 Auto Surcharge Appeal ”) B03 Motor Vehicle Negligence - Personal E47 Civil Rights Act, G.L. ¢.12 §t1H (A) Secrets A) Injury/Property Damage ) E24 Appeal from District Court 8G1 Financial Institutions/Funds @) B04 Other Negligence - Personal Commitment, G.L. ¢.123 §9(b) ”) BH1 Violation of Antitrust or Trade Injury/Property: Damage F) £25 Pleural Registry (Asbestos cases) Regulation Laws (A) 805 Products Liability (a) ‘A99 Other Contract/Business Action - Specify (F) E96 Forfeiture, G.L. 0.940. $47 (F) B06 Malpractice - Medical E99 Other Administrative Action ” B07 Malpractice - Other (A) 201 Medical Malpractice ~ Tribunal only, * Choose this case type if ANY party is the 808 Wrongful Death - Non-medical A) GL. c. 231 §60B ®) ‘Commonwealth, a municipality, the MBTA, or any 815 Defamation (A) Z02 Appeal Bond Denial ”) other governmental entity UNLESS your case is a B19 Asbestos @) case type listed under Administrative Civil Actions. B20 Personal injury - Slip & Fall (FY ‘SO Sex Offender Review (AA). 821 Environmental «) 822 Employment Discrimination (F) E12 SDP Commitment, G.L. ¢. 1234 §12 ~ + Choose this case type if ANY party is an BE1 Fraud, Business Torts, etc. 44 SDP Petition, G.L. c. 123A §9(b) ” incarcerated party, UNLESS your case is a case B99 Other Tortious Action ) type listed under Administrative Civil Actions (AA) RGRestricted Civil Actions oris a Prisoner Habeas Corpus case (E97). RP.Summary Process (Real Property} E19 Sex Offender Registry, G.L..6 §178M _ (X) 801 Summary Process - Residential ®) E27 Minor Seeking Consent, G.L. €.112 §128 (X) $02 Summary Process - Commercial! Non-residential ) "RANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? YES NO BOs Motor Vehicle Negligence-Personal Injury —E. STATEMENT OF DAMAGES PURSUANT TO G.L. c. 212, §3A as necessary), a DUTY OF THE PLAINTIFF - The plaintiff shall set forth, on the face of the civil action cover sheet (or attach additional sheets the statement specifying the facts on which the plaintiff relies to determine money damages. A copy of such civil action cover sheet, including clerk-magistrat e shall not accept for filing a complaint, except as. statement as to the damages, shall be served with the complaint. A ted litigant. otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or self-represen may DUTY OF THE DEFENDANT - If the defendant believes that the statement of damages filed by the plaintiff is inadequate, the defendant 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.