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DOCKET NUMBER Trial Court of Massachusetts
CIVIL ACTION COVER SHEET
ZA-B90V'133-D The Superior Court
PLAINTIFF(S): Silver hepcn o Lrvestoents LLC Woreeske—
ADDRESS: IT Preree. Ave Unt C.
FUcAbu nein AO jue verenoannsy Lice Balena LLC
Lawrence. Lagey
ATTORNEY: Gre mn. Pisaled Joshua Champa ene.
ADDRESS: jar “Prith ce St ADDRESS: [4 Purpork Ra
Folch bur NA alge Fobchbure YR ode
* 17 The?St
BBO: G8S%oT] Futthbur?g, Wm o14ee
1
TYPE OF ACTION AND TRACK DESIGNATION (see reverse side)
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
pag OCher Egint 4 (ves NO
‘If "Other" please describe:
‘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 counsel relies to determine money damages. For
this form, disregard double or treble damage claims; indicate single damages only.
cl
(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 .
5. Total other expenses (describe below)
Subtotal (
JUL 0 1 2024
|B. Documented lost wages and compensation to date
|C.:Documented property damages to dated ....
D. Reasonably anticipated future medical and hospital expenses CLE!
E. Reasonably anticipated lost wages .....
IF. Other documented items of damages (describe below)
|G. Briefly describe plaintiff's injury, including the nature and extent of injury:
Less of person properly, dapra ge +o personal 4 TOTAL (A-F):$ est 59, 00%
real preper
(attach additional sheets as necessary)
Provide a detailed description of claims(s):
TOTAL: $
Less of yalue fo Lave
Signature of Attorney/Pro Se Plaintiff: X Z) / AA ST). Lid ates .
mber, case name, and county of any related actions pending in the Superior Court.
Datei TA BY
ALIFSCYV bOI0
(/ CERTIFICATION PURSUANT TO SJC RULE 1:18
I hereby certify that | have complied with requirements of Rule 5 of the Supreme Judicial Court Uniform Rules on Dispute Resolution (SJC
Rule 1:18) requiring that | provide my clients with information about court-connected dispute resolution services and discuss with them the
Cf,
advantages and disadvantages’of the vari us methods of dispute resolution.
Yn. Fcatous
.
Signature of Attorney of Record: X Date: “7. / 24/
ZAK
CIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
AC Actions Involving the State/Municipality * ER Equitable Remedies RP
Property
Real
‘AAt Contract Action involving Commonwealth, DO1 Specific Performance of a Contract @) Ot Land Taking
Municipality, MBTA, etc, ) (002 Reach and Apply C02 Zoning Appeal, G.L. c. 404
AB1 Tortious Action involving Commonwealth, 1DO3 Injunction ) C03 Dispute Conceming Title
Municipality, MBTA, etc. 04 Reform/ Cancel Instrument F) C04 Foreclosure of a Mortgage a)
AC1 Real Property Action im DOS Equitable Replevin C05 Condominium Lien & Charges «)
;ommeonwealth, Municipality, MBTA etc, (A) (D06 Contribution or Indemnification (F) C99 Other Real Property Action Fy
‘AD1 Equity Action involving Commonwealth, D07 Imposition of a Trust (A)
Municipality, MBTA, etc. D08 Minority Shareholder's Suit -MC
Miscellaneous
Civil Actions
‘AE1 Administrative Action involvi 009 Interference in Contractual Relationship (F)
Commonwealth, Municipality, MBTA,etc. (A) D10 Accounting E18 Foreign Discovery Proceeding &)
D411 Enforcementof Restrictive Covenant ©) E97 Prisoner Habeas )
CN
Contract/Business
Cases D12 Dissolution of a Partnershi E22 Lottery Assignment, G.L. c. 10 §28 ”
013 Declaratory Judgment, G.L. c.231A (A)
A01 Services, Labor, and Materials © 14 Dissolution of a Corpor 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 © PA Civil Actions Involving Incarcerated
Party. + £21 Protection from Harassment, G.L. c. 258E(X)
‘A06 Insurance Contract
A08 Sale or Leaseof Real Estate PA‘ Contract Action involving an -AA
Administrative
Civil Actions.
‘A12.Construction Dispute . (A) Incarcerated Party a
A14 Interpleader © PBI Tortious Action involving an E02 Appeal from Administrative Agency,
BAt Governance, Conduct, Internal Incareer (A)
”)
Affairs of Entities C1 Real Property Action involving an 03 Certiorari Action, G.L. «.249 §4 &)
BAG Liabilityof Shareholders, Directors,
Incarcerate E05 Confirmation of Arbitration Awards ()
icers, Partners, etc. ®) 06 Mass Antitrust Act, G. L. c. 93 §9 A)
BB1 Shareholder Derivative PDt Equity Action involving an
(A) Incarcerated Par *) E07 Mass Antitrust
Act, G. L. c. 93 §8 a)
BB2 Securities Transactions a) PE1 Administrative Action involving an
E08 Appointment
of a Receiver ”)
BC1 Mergers, Consolidations, Sales of Incarcerated ©)
£09 Construction Surety Bond, G.L.c. 149
Assets, Issuance of Debt, Equity, @) §§29, 290 (a)
BD1 Intellectual Property £10 Summary Process Appeal &)
BD2 Proprietary Information or Trade. TR Torts, E11 Worker's Compensation ) _¥——--
‘Secrets a) B03 Motor Vehicle Negligence - Personal E16-AutoSi
8G1 Financial Institutions/Funds a) Injury/Property Damage E17 Civil Rights Act, G.L. ¢.12 §11H. a)
BH1 Violation of Antitrust or Trade: ©) E24 Appeal from District Court
ulation Laws B04 Other Negligence - Personal Commitment, G.L. 6.123 §9(b) «)
‘A99 Other Contract/Business Action - Specity (F) Injury/Property Damage (F) E25 Pleural Registry (Asbestos cases)
B05 Products Liability (A) E95 Forfeiture, G.L. c.94C §47
806 Malpractice - Medical / Wrongful Death @ E99 Other Administrative Action ®)
B07 Malpractice : Other (A) 201 Medical Malpractice - Tribunal only,
* Choose this case type if ANY party is the B08 Wrongful Death, G.L. ¢.229 §2A, a) GL, ¢. 231 §60B . fF
Coititnoniwealth, a municipality, the MBTA, or any B15 Defamation (ay Z02 Appeal Bond Denial @)
other governmentale1 ‘UNLESS your case isa B19 Asbestos @)
case type listed under Administrative Civil Actions 820 Persorial Injury - Slip & Fall SO Sex Offender Review
(AA) 24 Environmental F) -
B22 Employment Discrimination (F) 12 SDP Commitment, G.L. c, 123A §12 ”
+ Choose this case type if ANY party is an BE1 Fraud, Business Torts, etc. A) E14 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) RC
Restricted
Civil Actions
or is a Prisoner Habeas Corpus case (E97).
£19 Sex Offender Registry, G.L. c.6 §178M
£27 Minor Seeking Consent, G.L. c.112 §128 9
E94 Forfeiture, G.L. c265
TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
Motor Vehicle Negligence-Personal injury —E. YES (1 no
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),
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 pro se party.
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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qf) DOCKET NUMBER Trial Court of Massachusetts CIVIL ACTION COVER SHEET ZA-B90V'133-D The Superior Court PLAINTIFF(S): Silver hepcn o Lrvestoents LLC Woreeske— ADDRESS: IT Preree. Ave Unt C. FUcAbu nein AO jue verenoannsy Lice Balena LLC Lawrence. Lagey ATTORNEY: Gre mn. Pisaled Joshua Champa ene. ADDRESS: jar “Prith ce St ADDRESS: [4 Purpork Ra Folch bur NA alge Fobchbure YR ode * 17 The?St BBO: G8S%oT] Futthbur?g, Wm o14ee 1 TYPE OF ACTION AND TRACK DESIGNATION (see reverse side) CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? pag OCher Egint 4 (ves NO ‘If "Other" please describe: ‘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 counsel relies to determine money damages. For this form, disregard double or treble damage claims; indicate single damages only. cl (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 . 5. Total other expenses (describe below) Subtotal ( JUL 0 1 2024 |B. Documented lost wages and compensation to date |C.:Documented property damages to dated .... D. Reasonably anticipated future medical and hospital expenses CLE! E. Reasonably anticipated lost wages ..... IF. Other documented items of damages (describe below) |G. Briefly describe plaintiff's injury, including the nature and extent of injury: Less of person properly, dapra ge +o personal 4 TOTAL (A-F):$ est 59, 00% real preper (attach additional sheets as necessary) Provide a detailed description of claims(s): TOTAL: $ Less of yalue fo Lave Signature of Attorney/Pro Se Plaintiff: X Z) / AA ST). Lid ates . mber, case name, and county of any related actions pending in the Superior Court. Datei TA BY ALIFSCYV bOI0 (/ CERTIFICATION PURSUANT TO SJC RULE 1:18 I hereby certify that | have complied with requirements of Rule 5 of the Supreme Judicial Court Uniform Rules on Dispute Resolution (SJC Rule 1:18) requiring that | provide my clients with information about court-connected dispute resolution services and discuss with them the Cf, advantages and disadvantages’of the vari us methods of dispute resolution. Yn. Fcatous . Signature of Attorney of Record: X Date: “7. / 24/ ZAK CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE AC Actions Involving the State/Municipality * ER Equitable Remedies RP Property Real ‘AAt Contract Action involving Commonwealth, DO1 Specific Performance of a Contract @) Ot Land Taking Municipality, MBTA, etc, ) (002 Reach and Apply C02 Zoning Appeal, G.L. c. 404 AB1 Tortious Action involving Commonwealth, 1DO3 Injunction ) C03 Dispute Conceming Title Municipality, MBTA, etc. 04 Reform/ Cancel Instrument F) C04 Foreclosure of a Mortgage a) AC1 Real Property Action im DOS Equitable Replevin C05 Condominium Lien & Charges «) ;ommeonwealth, Municipality, MBTA etc, (A) (D06 Contribution or Indemnification (F) C99 Other Real Property Action Fy ‘AD1 Equity Action involving Commonwealth, D07 Imposition of a Trust (A) Municipality, MBTA, etc. D08 Minority Shareholder's Suit -MC Miscellaneous Civil Actions ‘AE1 Administrative Action involvi 009 Interference in Contractual Relationship (F) Commonwealth, Municipality, MBTA,etc. (A) D10 Accounting E18 Foreign Discovery Proceeding &) D411 Enforcementof Restrictive Covenant ©) E97 Prisoner Habeas ) CN Contract/Business Cases D12 Dissolution of a Partnershi E22 Lottery Assignment, G.L. c. 10 §28 ” 013 Declaratory Judgment, G.L. c.231A (A) A01 Services, Labor, and Materials © 14 Dissolution of a Corpor 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 © PA Civil Actions Involving Incarcerated Party. + £21 Protection from Harassment, G.L. c. 258E(X) ‘A06 Insurance Contract A08 Sale or Leaseof Real Estate PA‘ Contract Action involving an -AA Administrative Civil Actions. ‘A12.Construction Dispute . (A) Incarcerated Party a A14 Interpleader © PBI Tortious Action involving an E02 Appeal from Administrative Agency, BAt Governance, Conduct, Internal Incareer (A) ”) Affairs of Entities C1 Real Property Action involving an 03 Certiorari Action, G.L. «.249 §4 &) BAG Liabilityof Shareholders, Directors, Incarcerate E05 Confirmation of Arbitration Awards () icers, Partners, etc. ®) 06 Mass Antitrust Act, G. L. c. 93 §9 A) BB1 Shareholder Derivative PDt Equity Action involving an (A) Incarcerated Par *) E07 Mass Antitrust Act, G. L. c. 93 §8 a) BB2 Securities Transactions a) PE1 Administrative Action involving an E08 Appointment of a Receiver ”) BC1 Mergers, Consolidations, Sales of Incarcerated ©) £09 Construction Surety Bond, G.L.c. 149 Assets, Issuance of Debt, Equity, @) §§29, 290 (a) BD1 Intellectual Property £10 Summary Process Appeal &) BD2 Proprietary Information or Trade. TR Torts, E11 Worker's Compensation ) _¥——-- ‘Secrets a) B03 Motor Vehicle Negligence - Personal E16-AutoSi 8G1 Financial Institutions/Funds a) Injury/Property Damage E17 Civil Rights Act, G.L. ¢.12 §11H. a) BH1 Violation of Antitrust or Trade: ©) E24 Appeal from District Court ulation Laws B04 Other Negligence - Personal Commitment, G.L. 6.123 §9(b) «) ‘A99 Other Contract/Business Action - Specity (F) Injury/Property Damage (F) E25 Pleural Registry (Asbestos cases) B05 Products Liability (A) E95 Forfeiture, G.L. c.94C §47 806 Malpractice - Medical / Wrongful Death @ E99 Other Administrative Action ®) B07 Malpractice : Other (A) 201 Medical Malpractice - Tribunal only, * Choose this case type if ANY party is the B08 Wrongful Death, G.L. ¢.229 §2A, a) GL, ¢. 231 §60B . fF Coititnoniwealth, a municipality, the MBTA, or any B15 Defamation (ay Z02 Appeal Bond Denial @) other governmentale1 ‘UNLESS your case isa B19 Asbestos @) case type listed under Administrative Civil Actions 820 Persorial Injury - Slip & Fall SO Sex Offender Review (AA) 24 Environmental F) - B22 Employment Discrimination (F) 12 SDP Commitment, G.L. c, 123A §12 ” + Choose this case type if ANY party is an BE1 Fraud, Business Torts, etc. A) E14 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) RC Restricted Civil Actions or is a Prisoner Habeas Corpus case (E97). £19 Sex Offender Registry, G.L. c.6 §178M £27 Minor Seeking Consent, G.L. c.112 §128 9 E94 Forfeiture, G.L. c265 TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? Motor Vehicle Negligence-Personal injury —E. YES (1 no 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), 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 pro se party. 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.