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nN IUMBER Trial Court of Massachusetts
CIVIL ACTION COVER SHEET
4 §2voo3,15 The Superior Court
PLAINTIFF(S): ELAVON, INC. County NORFOLK
ADDRESS: C/O ZWICKER & ASSOCIATES, P.C.
225 FOXBOROUGH BLVD., STE 204 DEFENDANT(S): THE PULSE GROUP USA, INC.
FOXBOROUGH MA, 02035.
JENNIFER A. KIRKWOOD, ESQ. / FREDERICK B. SEITZ IV,
ATTORNEY: ESQ. / RICHARD VOLPE, ESQ. / JUSTIN T
ent: PHIL VENDETTI, 29 HAYWARD ST, FRANKLIN, MA
ADDRESS: 225 FOXBOROUGH BLVD., STE 204 ADDRESS: 02038
FOXBOROUGH MA, 02035,
BBO: # 667265, # 684656, # 631657, # 685973
TYPE OF ACTION AND TRACK DESIGNATION (see reverse side)
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
Ag9 Credit Account F Yes a No
*If “Other” please describe:
Is there a claim under G.L. c. 93A? Is this a class action under Mass. R. Civ. P.23?
O YES ON O YES ONO
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 plaintiff's 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 a $§
3. Total chiropractic expenses
4. Total physical therapy expenses +... ——_|
5. Total other expenses (describe) a
Subtotal (A)
IB. Documented lost wages and compensation to date
IC. Documented property damages to date oy
D. Reasonably anticipated future medical and hospital expenses
IE. Reasonably anticipated lost wages
IF. Other documented items of damages (describe below)
IG. Briefly describe plaintiff's injury, including nature and extent of injury
Total (A-F):$
CONTRACT CLAIMS
(attach additional sheets as necessary)
O This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass.
IR. Civ. P. 8.1(a).
Provide a detailed description of claim(s):
Breach of Credit Agreement TOTAL $ 50,828.50
Signature of Attorney/ Unrepresented Plaintiff:
RELATED ACTIONS: Please provide the case wien m
we #. IY
case name, a
Date:
any related actions pending in the Superior Court.
%/@, laf
on PURSUANT OT SJC RULE 1:18
Ihereby certify that I have complied with the requirements of Rule 5 of the Supreme Judicial Court Uniform Rules on Dispute Resolution (SJC
Rule 1:18) requiring that I provide my clients with information about court-connected dispute resolution services and discuss with them the
advantages and disadvantages of th«ORSof, er resolution.
Signature of Attorney of Record: X Date: “2, Jey
267700030637
CIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
AC Actions Involving the State/Municipality* ER Equitable Remedie: RP Real Property
AAI Contract Action Involving Commonwealth, DO1 Specific Performance of a Contract (a) C01 Land Taking (F)
Municipality, MBTA, etc. (A) D02 Reach and Apply (F) C02 Zoning Appeal, G.L. c. 404. (F)
AB2 Tortious Action involving Commonwealth, 03 Injunction
Municipality, MBTA, etc. (A)
(F) C03 Dispute Concerning Title (F)
ACI Real Property Action involving Commonwealth,
04 Reform/ Cancel Instrument (F) C04 Foreclosure of a Mortgage ”
(a) DOS Equitable Replevin (F) C05 Condominium Lien & Charges
Municipality, MBTA, etc. ”
AD1 Equity Action involving Commonwealth, 06 Contribution or Indemnification
DO7 Imposition of a Trust
(F) C99 Other Real Property Action (F)
Municipality, MBTA, etc. (A (A)
AE Administrative Action involving Commonwealth, 108 Minority Shareholder’s Suit (A) MC Miscellaneous Civil Actions
Municipality, MBTA, etc. DOS Interference in Contractual Relationship (F)
10 Accounting (A) E18 Foreign Discovery Proceeding ”
CN Contract/Business Cases D11 Enforcement of Restrictive Covenant E97 Prisoner Habeas Corpus
(F) ”
A01 Services, Labor, and Materials (F) D12 Dissolution of a Partnership F) E22 Lottery Assignment, G.L. c. 10 §28 ”
A02 Goods Sold and Delivered (F) D13 Declaratory Judgment, G.L. ¢.231A A)
D144 Dissolution of a Corporation (F) ‘AB Abuse/Harassment Preventior
A03 Commercial Paper (F)
A04 Employment Contract F) D99 Other Equity Action (F)
AOS Consumer Revolving Credit - M.R.C.P. 8.1 (F) E15 Abuse Prevention Petition, G.L. c. 209A ”
A06 Insurance Contract (F) PA Givil Actions Involving Incarcerated Party t E21 Protection from Harassment, G.L. c. 258 ”
A08 Sale or Lease of Real Estate (F) PAM Contract Action involving an
A12 Construction Dispute AA Administrative Civil Action:
(A) Incarcerated Party ()
14 Interpleader (F) PB1 Tortious Action involving an E02 Appeal from Administrative Agency,
BA1 Governance, Conduct, Internal Incarcerated Pat (A) G.L. c. 30A(X)
Affairs of Entities (A) PC1 Real Property Action involving an
BA3 Liability of Shareholders, Directors, Incarcerated Party (F) E03 Certiorari Action, G.L. ¢.249 §4 ”
Officers, Partners, etc. (a) PD1 Equity Action involving an E05 Confirmation of Arbitration Awards ~
BB1 Shareholder Derivative (A)
Incarcerated Party (F) E06 Mass Antitrust Act, G. L.c. 93 §9 (A)
BB2 Securities Transactions
PE1 Administrative Action involving an E07 Mass Antitrust Act, G. L. c. 93 §8 ®)
(A) Incarcerated Party )
BC1 Mergers, Consolidations, Sales of E08 Appointment of a Receiver ”
Assets, Issuance of Debt, Equity, etc. (A) TR Torts E09 Construction Surety Bond, G.L. c. 149
D1 Intellectual Property (A) B03 Motor Vehicle Negligence - Personal 1829, 2A (A)
BD2 Proprietary Information or Trade Injury/Property Damage E10 Summary Process Appeal &”)
Secrets (a) (F)
8G1 Financial Institutions/Funds (A)
B04 Other Negligence - Personal E11 Worker's Compensation &®)
BH1 Violation of Antitrust or Trade Injury/Property Damage (F) E16 Auto Surcharge Appeal ®)
BOS Products Liability (A) E17 Civil Rights Act, G.L. c.12 §11H (A)
Regulation Laws (A)
A99 Other Contract/Business Action - Specify (F) B06 Malpractice - Medical (A) E24 Appeal from District Court
B07 Malpractice - Other (A) Commitment, G.L. ¢.123 §9(b)
* Choose this case type if ANY party is the B08 Wrongful Death - Non-medical (A) E25 Pleural Registry (Asbestos cases)
Commonwealth, a municipality, the MBTA, or any other B15 Defamation ) E95 Forfeiture, G.L. ¢.94C §47 (F)
governmental entity UNLESS your case is a case type B19 Asbestos (A) E99 Other Administrative Action )
listed under Administrative Civil Actions (AA). B20 Personal Injury - Slip & Fall (F) 201 Medical Malpractice - Tribunal only,
B21 Environmental (F)
+ Choose this case type if ANY party is an incarcerated B22 Employment Discrimination GL. c. 231 §60B (F)
party, UNLESS your case is a case type listed under (F) 202 Appeal Bond Denial ”
Administrative Civil Actions (AA) or is a Prisoner Habeas BE1 Fraud, Business Torts, etc. “A
Corpus case (E97). B99 Other Tortious Action (F) SO Sex Offender Review
RP Summary Process (Real Property) E12 SDP Commitment, G.L. c. 123A §12 ~
$01 Summary Process — Residential ” E14 SDP Petition, G. ©. 123A §9(b) ”
$02 Summary Process - Commercial!
Non-residential (F) RCRestricted
Civil Actions
E19 Sex Offender Registry, G.L. c.6 §178M ~
E27 Minor Seeking Consent, G.L. c.112 §12S. ”
TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
B03 Motor Vehicle Negligence-Personal Injury F YES Ono
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.
ACIVIL ACTION COVER SHEET MUST BE FILED WITH EACH COMPLAINT.
FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY
MAY RESULT IN DISMISSAL OF THIS ACTION.
267700030637
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nN IUMBER Trial Court of Massachusetts CIVIL ACTION COVER SHEET 4 §2voo3,15 The Superior Court PLAINTIFF(S): ELAVON, INC. County NORFOLK ADDRESS: C/O ZWICKER & ASSOCIATES, P.C. 225 FOXBOROUGH BLVD., STE 204 DEFENDANT(S): THE PULSE GROUP USA, INC. FOXBOROUGH MA, 02035. JENNIFER A. KIRKWOOD, ESQ. / FREDERICK B. SEITZ IV, ATTORNEY: ESQ. / RICHARD VOLPE, ESQ. / JUSTIN T ent: PHIL VENDETTI, 29 HAYWARD ST, FRANKLIN, MA ADDRESS: 225 FOXBOROUGH BLVD., STE 204 ADDRESS: 02038 FOXBOROUGH MA, 02035, BBO: # 667265, # 684656, # 631657, # 685973 TYPE OF ACTION AND TRACK DESIGNATION (see reverse side) CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? Ag9 Credit Account F Yes a No *If “Other” please describe: Is there a claim under G.L. c. 93A? Is this a class action under Mass. R. Civ. P.23? O YES ON O YES ONO 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 plaintiff's 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 a $§ 3. Total chiropractic expenses 4. Total physical therapy expenses +... ——_| 5. Total other expenses (describe) a Subtotal (A) IB. Documented lost wages and compensation to date IC. Documented property damages to date oy D. Reasonably anticipated future medical and hospital expenses IE. Reasonably anticipated lost wages IF. Other documented items of damages (describe below) IG. Briefly describe plaintiff's injury, including nature and extent of injury Total (A-F):$ CONTRACT CLAIMS (attach additional sheets as necessary) O This action includes a claim involving collection of a debt incurred pursuant to a revolving credit agreement. Mass. IR. Civ. P. 8.1(a). Provide a detailed description of claim(s): Breach of Credit Agreement TOTAL $ 50,828.50 Signature of Attorney/ Unrepresented Plaintiff: RELATED ACTIONS: Please provide the case wien m we #. IY case name, a Date: any related actions pending in the Superior Court. %/@, laf on PURSUANT OT SJC RULE 1:18 Ihereby certify that I have complied with the requirements of Rule 5 of the Supreme Judicial Court Uniform Rules on Dispute Resolution (SJC Rule 1:18) requiring that I provide my clients with information about court-connected dispute resolution services and discuss with them the advantages and disadvantages of th«ORSof, er resolution. Signature of Attorney of Record: X Date: “2, Jey 267700030637 CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE AC Actions Involving the State/Municipality* ER Equitable Remedie: RP Real Property AAI Contract Action Involving Commonwealth, DO1 Specific Performance of a Contract (a) C01 Land Taking (F) Municipality, MBTA, etc. (A) D02 Reach and Apply (F) C02 Zoning Appeal, G.L. c. 404. (F) AB2 Tortious Action involving Commonwealth, 03 Injunction Municipality, MBTA, etc. (A) (F) C03 Dispute Concerning Title (F) ACI Real Property Action involving Commonwealth, 04 Reform/ Cancel Instrument (F) C04 Foreclosure of a Mortgage ” (a) DOS Equitable Replevin (F) C05 Condominium Lien & Charges Municipality, MBTA, etc. ” AD1 Equity Action involving Commonwealth, 06 Contribution or Indemnification DO7 Imposition of a Trust (F) C99 Other Real Property Action (F) Municipality, MBTA, etc. (A (A) AE Administrative Action involving Commonwealth, 108 Minority Shareholder’s Suit (A) MC Miscellaneous Civil Actions Municipality, MBTA, etc. DOS Interference in Contractual Relationship (F) 10 Accounting (A) E18 Foreign Discovery Proceeding ” CN Contract/Business Cases D11 Enforcement of Restrictive Covenant E97 Prisoner Habeas Corpus (F) ” A01 Services, Labor, and Materials (F) D12 Dissolution of a Partnership F) E22 Lottery Assignment, G.L. c. 10 §28 ” A02 Goods Sold and Delivered (F) D13 Declaratory Judgment, G.L. ¢.231A A) D144 Dissolution of a Corporation (F) ‘AB Abuse/Harassment Preventior A03 Commercial Paper (F) A04 Employment Contract F) D99 Other Equity Action (F) AOS Consumer Revolving Credit - M.R.C.P. 8.1 (F) E15 Abuse Prevention Petition, G.L. c. 209A ” A06 Insurance Contract (F) PA Givil Actions Involving Incarcerated Party t E21 Protection from Harassment, G.L. c. 258 ” A08 Sale or Lease of Real Estate (F) PAM Contract Action involving an A12 Construction Dispute AA Administrative Civil Action: (A) Incarcerated Party () 14 Interpleader (F) PB1 Tortious Action involving an E02 Appeal from Administrative Agency, BA1 Governance, Conduct, Internal Incarcerated Pat (A) G.L. c. 30A(X) Affairs of Entities (A) PC1 Real Property Action involving an BA3 Liability of Shareholders, Directors, Incarcerated Party (F) E03 Certiorari Action, G.L. ¢.249 §4 ” Officers, Partners, etc. (a) PD1 Equity Action involving an E05 Confirmation of Arbitration Awards ~ BB1 Shareholder Derivative (A) Incarcerated Party (F) E06 Mass Antitrust Act, G. L.c. 93 §9 (A) BB2 Securities Transactions PE1 Administrative Action involving an E07 Mass Antitrust Act, G. L. c. 93 §8 ®) (A) Incarcerated Party ) BC1 Mergers, Consolidations, Sales of E08 Appointment of a Receiver ” Assets, Issuance of Debt, Equity, etc. (A) TR Torts E09 Construction Surety Bond, G.L. c. 149 D1 Intellectual Property (A) B03 Motor Vehicle Negligence - Personal 1829, 2A (A) BD2 Proprietary Information or Trade Injury/Property Damage E10 Summary Process Appeal &”) Secrets (a) (F) 8G1 Financial Institutions/Funds (A) B04 Other Negligence - Personal E11 Worker's Compensation &®) BH1 Violation of Antitrust or Trade Injury/Property Damage (F) E16 Auto Surcharge Appeal ®) BOS Products Liability (A) E17 Civil Rights Act, G.L. c.12 §11H (A) Regulation Laws (A) A99 Other Contract/Business Action - Specify (F) B06 Malpractice - Medical (A) E24 Appeal from District Court B07 Malpractice - Other (A) Commitment, G.L. ¢.123 §9(b) * Choose this case type if ANY party is the B08 Wrongful Death - Non-medical (A) E25 Pleural Registry (Asbestos cases) Commonwealth, a municipality, the MBTA, or any other B15 Defamation ) E95 Forfeiture, G.L. ¢.94C §47 (F) governmental entity UNLESS your case is a case type B19 Asbestos (A) E99 Other Administrative Action ) listed under Administrative Civil Actions (AA). B20 Personal Injury - Slip & Fall (F) 201 Medical Malpractice - Tribunal only, B21 Environmental (F) + Choose this case type if ANY party is an incarcerated B22 Employment Discrimination GL. c. 231 §60B (F) party, UNLESS your case is a case type listed under (F) 202 Appeal Bond Denial ” Administrative Civil Actions (AA) or is a Prisoner Habeas BE1 Fraud, Business Torts, etc. “A Corpus case (E97). B99 Other Tortious Action (F) SO Sex Offender Review RP Summary Process (Real Property) E12 SDP Commitment, G.L. c. 123A §12 ~ $01 Summary Process — Residential ” E14 SDP Petition, G. ©. 123A §9(b) ” $02 Summary Process - Commercial! Non-residential (F) RCRestricted Civil Actions E19 Sex Offender Registry, G.L. c.6 §178M ~ E27 Minor Seeking Consent, G.L. c.112 §12S. ” TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? B03 Motor Vehicle Negligence-Personal Injury F YES Ono 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. ACIVIL ACTION COVER SHEET MUST BE FILED WITH EACH COMPLAINT. FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY MAY RESULT IN DISMISSAL OF THIS ACTION. 267700030637