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2 J
DOCKET NUMBER: Trial Court of Massachusetts
CIVIL ACTION COVER SHEET The Superior Court
AUC WGA
puammins: AD Ase _. Pra e |COUNTY
“ADDRESS:
oV25x |_
SO2-BP) 40 £9 DEFENDANT(S):
LiLig a. _Lilapilage
ATTORNEY:
Wi fe itrt
_ADDRESS: ge
LA Ber
fiveae ti
‘ADDRESS: SUE
BBO:
TYPE OF ACTION AND TRRGK DESIGNATION (see reverse side)
CODE NO. TYPE OF ACTION (specify) TRA HAS A JURY CLAIM BEEN MADE?
CO ves (J xo
pas
*If"Other" please describe:
Is there a claim under ote , 983A? Is this a class action under Mass. R. Civ. P, 23?
YES
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 plaintiff's counsel relies to determine money damages.
For this form, disregard double or treble damage claims; indicate single damages only.
TORT
(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 therapy expenses . Wie
5. Total other expenses (describe below)
onhe OURHAT.
QE HIODLESEX ‘Subtotal (A):
2OR GBUNE
|B, Documented lost wages and compensation to date
MAR: 2024
C. Documented property damages to date :.
ID. Reasonably anticipated future medical and hospital expenses . sy
|E. Reasonably anticipated lost wages . J
IF, Other documented items of damages (describe below) .
‘é,
Lo
G. Briefly describe plant's 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: Date:
Court.
RELATED ACTIONS: Please provide the case number, case name, and county of any related actions pending in the Superior
CERTIFICATION PURSUANT TO SJC RULE 4:18
(SJC
| hereby certify that | have complies d with requirements of Rule 5 of the Supreme Judicial Court Uniform.Rules on Dispute Resolution
resoluti ion services and discuss with them the
Rule 1:18) requiring that | provide my clients with information about court-connected dispute
advantages and disadvantages of the various methods of dispute resolution.
Signature of Attorney of Record: X SLE Date: 3. Y L2. y
CIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
‘AC Actions involving the State/Munlefpality ~ ER Equitable Remedies RP
Property
Real
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. ¢. 40A (F)
ABI Tortious Action involving Commonwealth, ‘03 Injunction ©) C03 Dispute Concerning Title ()
Municipality, MBTA, ete. 104 Reform/ Cancel Instrument C04 Foreclosure of a Mortgage
AC1 Real Property Action involving 05 Equitable Replevin C05 Condominium Lien & Charges
Commonwealth, Municipality, MBTA etc. (A) 06 Contribution or Indemnification (F) C99 Other Real Property Action
‘AD4 Equity Action involving Commonwealth, 07 Imposition of a Trust (a)
-MC
Miscellaneous
Civil Actions
‘Municipatity, MBTA, etc, a) 008 Minority Shareholder’s Suit (A)
‘AE1 Administrative Action involving 08 Interference in Contractual Relationship F)
‘Commonwealth, Municipality, MBTA,etc. (A) 010 Accounting E18 Foreign Discovery Proceeding ®
D11 Enforcement of Restrictive Covenant E97 Prisoner Habeas Corpus.
CN
Contract/Business
Cases D412 Dissolution of a Partnershif £22 Lottery Assignment, G.L. c. 10 §28
D13 Declaratory Judgment, G.L. .231A a)
AO1 Services, Labor, and Materials (Ff) 14 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)
E21 Protection trom Harassment, G.L. c, 258E(X)
A04
AS
Employment Contract
Consumer Revolving Credit - mance. a,
PA.Givil Actions Involving Incarcerated
Party +
© AA
Administrative
Givil Actions
A06 Insurance Contract PA Contract Action involving an
A08 Sale or Lease of Real Estate (F) Incarcerated Party A) £02 Appeal from Administrative Agency,
A12 Construction Dispute @ PBI Tortious Action involving an ob.@, 3
14 Interpleader © Incarcerated Par £03 Certiorari Action, G.L. 0.249 §4
BA1 Governance, Conduct, Internal PC1 Real Property Action involving an
Affairs of Entities A £05 Confirmation of Arbitration Awards ®)
BAS Liability of Shareholders, Directors, Incarcerated P: fF) E06 Mass Antitrust Act, G. L. c, 93 §9 @)
Officers, Partners, etc.
PD1 Equity Action involving an E07 Mass Antitrust Act, G. L. c. 93 §8
@ Incarcerated Par F) E08 Appointment of a Receiver
BB1 Shareholder Derivative @ PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. c. 149
BB2 Securities Transactions @) Incarcerated Party )
BC1 Mergers, Consolidations, Sales of §§29, 288, A)
Assets, Issuance of Debt, Equity, etc. @ E10 Summary Process Appeal
8D1 Intellectual Property IR Torts E11 Worker's Compensation &)
B02 Proprietary Information or Trade E18 Auto Surcharge Appeal
B03 Motor Vehicle Negligence - Personal E47 Civil Rights Act, G.L. c.12 §11H @
Secrets A) Injury/Property Damage ) E24 Appeal fram District Court
8G1 Financial Institutions/Funds @ B04 Other Negligence - Personal
BH1 Violation of Antitrust or Trade Commitment, G.L. 6.123 §9(b)
Injury/Property Damage £25 Pleural Registry (Asbestos cases)
Regulation Laws
A99 Other Contract/Business Action - Specify 6 BOS Products Liability
B06 Malpractice - Medical
“a
@)
E95 Forfeiture, G.L, ¢.94C §47
E99 Other Administrative Action
F)
”
B07 Malpractice- Other @ 201 Medical Malpractice - Tribunal only,
808 Wrongful Death - Non-medical
* Choose this case type if ANY party is the
Commonwealth, a municipality, the MBTA, or any
other governmental entity UNLESS your case is a
B15
B19
Defamation
Asbestos
A) G.L.c. 231 §80B
Z02 Appeal Bond Denial %
case type listed under Administrative Civil Actions 820 Personal Injury - Slip & Fall (F) SO Sex Offender Review
(AA). B21 Environmental ©)
B22 Employment Discrimination «F) £12 SDP Commitment, G.L. ¢..123A §12 «
+t Choose this case type if ANY party is an BE1 Fraud, Business Torts, etc. A) E44 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) RCRestricted
Civil Aetions
or is a Prisoner Habeas Corpus case (E97). RP Summary Process (Real Property)
E19 Sex Offender Registry, G.L. 0.6 §178M ©
$01 Summary Process - Residential 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 N
BOs Motor Vehicle Negligence-Personal Injury A.
STATEMENT OF DAMAGES PURSUANT TO G.L. 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, 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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2 J DOCKET NUMBER: Trial Court of Massachusetts CIVIL ACTION COVER SHEET The Superior Court AUC WGA puammins: AD Ase _. Pra e |COUNTY “ADDRESS: oV25x |_ SO2-BP) 40 £9 DEFENDANT(S): LiLig a. _Lilapilage ATTORNEY: Wi fe itrt _ADDRESS: ge LA Ber fiveae ti ‘ADDRESS: SUE BBO: TYPE OF ACTION AND TRRGK DESIGNATION (see reverse side) CODE NO. TYPE OF ACTION (specify) TRA HAS A JURY CLAIM BEEN MADE? CO ves (J xo pas *If"Other" please describe: Is there a claim under ote , 983A? Is this a class action under Mass. R. Civ. P, 23? YES 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 plaintiff's counsel relies to determine money damages. For this form, disregard double or treble damage claims; indicate single damages only. TORT (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 therapy expenses . Wie 5. Total other expenses (describe below) onhe OURHAT. QE HIODLESEX ‘Subtotal (A): 2OR GBUNE |B, Documented lost wages and compensation to date MAR: 2024 C. Documented property damages to date :. ID. Reasonably anticipated future medical and hospital expenses . sy |E. Reasonably anticipated lost wages . J IF, Other documented items of damages (describe below) . ‘é, Lo G. Briefly describe plant's 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: Date: Court. RELATED ACTIONS: Please provide the case number, case name, and county of any related actions pending in the Superior CERTIFICATION PURSUANT TO SJC RULE 4:18 (SJC | hereby certify that | have complies d with requirements of Rule 5 of the Supreme Judicial Court Uniform.Rules on Dispute Resolution resoluti ion services and discuss with them the Rule 1:18) requiring that | provide my clients with information about court-connected dispute advantages and disadvantages of the various methods of dispute resolution. Signature of Attorney of Record: X SLE Date: 3. Y L2. y CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE ‘AC Actions involving the State/Munlefpality ~ ER Equitable Remedies RP Property Real 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. ¢. 40A (F) ABI Tortious Action involving Commonwealth, ‘03 Injunction ©) C03 Dispute Concerning Title () Municipality, MBTA, ete. 104 Reform/ Cancel Instrument C04 Foreclosure of a Mortgage AC1 Real Property Action involving 05 Equitable Replevin C05 Condominium Lien & Charges Commonwealth, Municipality, MBTA etc. (A) 06 Contribution or Indemnification (F) C99 Other Real Property Action ‘AD4 Equity Action involving Commonwealth, 07 Imposition of a Trust (a) -MC Miscellaneous Civil Actions ‘Municipatity, MBTA, etc, a) 008 Minority Shareholder’s Suit (A) ‘AE1 Administrative Action involving 08 Interference in Contractual Relationship F) ‘Commonwealth, Municipality, MBTA,etc. (A) 010 Accounting E18 Foreign Discovery Proceeding ® D11 Enforcement of Restrictive Covenant E97 Prisoner Habeas Corpus. CN Contract/Business Cases D412 Dissolution of a Partnershif £22 Lottery Assignment, G.L. c. 10 §28 D13 Declaratory Judgment, G.L. .231A a) AO1 Services, Labor, and Materials (Ff) 14 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) E21 Protection trom Harassment, G.L. c, 258E(X) A04 AS Employment Contract Consumer Revolving Credit - mance. a, PA.Givil Actions Involving Incarcerated Party + © AA Administrative Givil Actions A06 Insurance Contract PA Contract Action involving an A08 Sale or Lease of Real Estate (F) Incarcerated Party A) £02 Appeal from Administrative Agency, A12 Construction Dispute @ PBI Tortious Action involving an ob.@, 3 14 Interpleader © Incarcerated Par £03 Certiorari Action, G.L. 0.249 §4 BA1 Governance, Conduct, Internal PC1 Real Property Action involving an Affairs of Entities A £05 Confirmation of Arbitration Awards ®) BAS Liability of Shareholders, Directors, Incarcerated P: fF) E06 Mass Antitrust Act, G. L. c, 93 §9 @) Officers, Partners, etc. PD1 Equity Action involving an E07 Mass Antitrust Act, G. L. c. 93 §8 @ Incarcerated Par F) E08 Appointment of a Receiver BB1 Shareholder Derivative @ PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. c. 149 BB2 Securities Transactions @) Incarcerated Party ) BC1 Mergers, Consolidations, Sales of §§29, 288, A) Assets, Issuance of Debt, Equity, etc. @ E10 Summary Process Appeal 8D1 Intellectual Property IR Torts E11 Worker's Compensation &) B02 Proprietary Information or Trade E18 Auto Surcharge Appeal B03 Motor Vehicle Negligence - Personal E47 Civil Rights Act, G.L. c.12 §11H @ Secrets A) Injury/Property Damage ) E24 Appeal fram District Court 8G1 Financial Institutions/Funds @ B04 Other Negligence - Personal BH1 Violation of Antitrust or Trade Commitment, G.L. 6.123 §9(b) Injury/Property Damage £25 Pleural Registry (Asbestos cases) Regulation Laws A99 Other Contract/Business Action - Specify 6 BOS Products Liability B06 Malpractice - Medical “a @) E95 Forfeiture, G.L, ¢.94C §47 E99 Other Administrative Action F) ” B07 Malpractice- Other @ 201 Medical Malpractice - Tribunal only, 808 Wrongful Death - Non-medical * Choose this case type if ANY party is the Commonwealth, a municipality, the MBTA, or any other governmental entity UNLESS your case is a B15 B19 Defamation Asbestos A) G.L.c. 231 §80B Z02 Appeal Bond Denial % case type listed under Administrative Civil Actions 820 Personal Injury - Slip & Fall (F) SO Sex Offender Review (AA). B21 Environmental ©) B22 Employment Discrimination «F) £12 SDP Commitment, G.L. ¢..123A §12 « +t Choose this case type if ANY party is an BE1 Fraud, Business Torts, etc. A) E44 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) RCRestricted Civil Aetions or is a Prisoner Habeas Corpus case (E97). RP Summary Process (Real Property) E19 Sex Offender Registry, G.L. 0.6 §178M © $01 Summary Process - Residential 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 N BOs Motor Vehicle Negligence-Personal Injury A. STATEMENT OF DAMAGES PURSUANT TO G.L. 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, 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.