On May 07, 2018 a
Miscellaneous
was filed
involving a dispute between
Clark, Karen,
and
Clark, Jr., Howard,
for Administrative Civil Actions
in the District Court of Nantucket County.
Preview
AL e @
DOCKET NUMBER Trial Court of Massachusetts
CIVIL ACTION COVER SHEET \eI1ScVvo00 17 The Superior Court
PLAINTIFFS: = Koren OK COUNTY
ADORESS: 8 Suns Aven Palm Beh FL SSB Nlawhooke-
DEFENDANTIS}: Howard Clark, Jr.
ATTORNEY: Donald G. Tye
ADDRESS: Prince Lobel Tye, LLP ADDRESS: 607 West Lyons Farm Drive, Greenwich, CT 06831
‘One international Place, Suite 3700
Boston, MA 02110
BBO:
TYPE OF ACTION AND TRACK DESIGNATION (see reverse side)
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
E99 Deposition of Out of State Witness CyYes [x] No
*H “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 onty.
TORT.CLAIMS
(attach additional sheets as necessary)
lA. Documented medical expenses to date: FILE
1. Total hospital expenses Je
2. Total doctor expenses
3. Total chiropractic expenses
4. Total physical therapy expenses
5. Total other expenses (describe
IB, Documented lost wages and compensation to date
IC. Documented property damages to dated ....
ID. Reasonably anticipated future medical and hospital expenses
|E, Reasonably anticipated lost wages ...........+
IF, Other documented items of damages (describe below!
PRHOW ANBOBE
IG. Briefly describe plaintiffs injury, including the nature and extent of injury:
TOTAL (A-F):S
GONTRACT CLAIMS
(attach additional sheets as necessary)
Provide a detailed description of claims(s):
TOTAL: $
Signature of Attorney/Pro Se Plaintiff: N Date: . Ss | 4 | &
RELATED ACTIONS: Please provide the case rlumber, case name, and county of any related actions pending in the Superior Court.
FST-FA-10-4018455-S Howard Clark, Jr. v. Karen K. lark Superior Court of the State of Connecticut Judicial District of Stamford-Norwalk
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 Resofution (SJC
Rule 1:18) requiring that | provide my clients with information about court-connected dispute resolution services and discuss with them the
ladvantages and disadvantages of the various|Methods of dispute resolution.
Signature of Attorney of Record: X (N Date: s] Y | j a
Document Filed Date
May 07, 2018
Case Filing Date
May 07, 2018
Category
Administrative Civil Actions
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AL e @ DOCKET NUMBER Trial Court of Massachusetts CIVIL ACTION COVER SHEET \eI1ScVvo00 17 The Superior Court PLAINTIFFS: = Koren OK COUNTY ADORESS: 8 Suns Aven Palm Beh FL SSB Nlawhooke- DEFENDANTIS}: Howard Clark, Jr. ATTORNEY: Donald G. Tye ADDRESS: Prince Lobel Tye, LLP ADDRESS: 607 West Lyons Farm Drive, Greenwich, CT 06831 ‘One international Place, Suite 3700 Boston, MA 02110 BBO: TYPE OF ACTION AND TRACK DESIGNATION (see reverse side) CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? E99 Deposition of Out of State Witness CyYes [x] No *H “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 onty. TORT.CLAIMS (attach additional sheets as necessary) lA. Documented medical expenses to date: FILE 1. Total hospital expenses Je 2. Total doctor expenses 3. Total chiropractic expenses 4. Total physical therapy expenses 5. Total other expenses (describe IB, Documented lost wages and compensation to date IC. Documented property damages to dated .... ID. Reasonably anticipated future medical and hospital expenses |E, Reasonably anticipated lost wages ...........+ IF, Other documented items of damages (describe below! PRHOW ANBOBE IG. Briefly describe plaintiffs injury, including the nature and extent of injury: TOTAL (A-F):S GONTRACT CLAIMS (attach additional sheets as necessary) Provide a detailed description of claims(s): TOTAL: $ Signature of Attorney/Pro Se Plaintiff: N Date: . Ss | 4 | & RELATED ACTIONS: Please provide the case rlumber, case name, and county of any related actions pending in the Superior Court. FST-FA-10-4018455-S Howard Clark, Jr. v. Karen K. lark Superior Court of the State of Connecticut Judicial District of Stamford-Norwalk 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 Resofution (SJC Rule 1:18) requiring that | provide my clients with information about court-connected dispute resolution services and discuss with them the ladvantages and disadvantages of the various|Methods of dispute resolution. Signature of Attorney of Record: X (N Date: s] Y | j a