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DOCKET NUMBER Trial Court of Massachusetts
CIVIL ACTION COVER SHEET
The Superior Court
PLAINTIFF(S): Lorin P. Burrows |COUNTY
ADDRESS: 20 Dowds Lane. Princeton, MA 01541 Worcester
DEFENDANT(S): Janet L. Cassidy, 109 S. Main Street, Millbury, MA
01527
ATTORNEY: Gregory W. Wheeler
ADDRESS: 15 Monument Sq., Suite 225, Leominster, MA ADDRESS:
01453
BBO: 669202
TYPE OF ACTION AND TRACK DESIGNATION (see reverse side)
CODE NO. TYPE OF ACTION (specify) Cl HAS A JURY CLAIM BEEN MADE?
A99
& D13 Breach of Fiduciary Duty of Trustee F (Yes 0 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?
YES NO YES NO
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 plaintiffs counsel relies to determine money damages.
For this form, disregard double or treble damage claims; indicate single damages only.
‘(ORT CLAIMS
(attach additional sheets as necessary)
. 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 b
Subtotal (A):
. Documented lost wages and compensation to date .
. Documented property damages to date .....
. Reasonably anticipated future medical and hospital expense:
. Reasonably anticipated lost wages .....
. Other documented items of damages (describe below)
IG. Briefly describe plaintiff's injury, including the nature and extent of injury:
TOTAL (A-F):$
(attach additional sheets as necessary)
[1 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): Defendant has failed to administer irrevocable trust according to its terms.
TOTAL: $
Plaintiff seeks to enforce the terms of the Trust and to recover damages equivalent to benefits he reasonably
eynected to receive Plaintiff alen ceeks declaratory and ininnetive relief
Signature of Attorney/ Unrepresented Plaintiff: X Date: 12/2/2020
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
ladvantages and disadvantages of the various methods of dispute resolution.
a Ne 12/2/2020
Signature of Attorney of Record: X Date:
CIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
Acti Involvin, Municii * R Equitable Remedies. Real Property
‘AA1 Contract Action involving Commonwealth, D01 Specific Performance of a Contract (A) 01 Land Taking (F)
Municipality, MBTA, etc. (A) Do2 Reach and Apply (F) C02 Zoning Appeal, G.L. c. 408 (F)
AB1 Tortious Action involving Commonwealth, 03 Injunction (F) C03 Dispute Concerning Title (F)
Municipality, MBTA, etc. (A) D04 Reform/ Cancel Instrument () C04 Foreclosure of a Mortgage (Xx)
AC1 Real Property Action involving DO5 Equitable Replevin (F) COS Condominium Lien & Charges (x)
Commonwealth, Municipality, MBTA etc. (A) D06 Contribution or Indemnification (F) C99 Other Real Property Action (F)
AD1 Equi Action involving Commonwealth, DO7 Imposition of a Trust (A)
Municipality, MBTA, etc. (A) Do8 Minority Shareholder's Suit (A) -MC
Miscellaneous
Civil Actions
‘AE1 Administrative Action involving D9 Interference in Contractual Relationship (F)
Commonwealth, Municipality, MBTA,etc. (A) D10 Accounting (A) E18 Foreign Discovery Proceeding (x)
D114 Enforcement of Restrictive Covenant (F) E97 Prisoner Habeas Corpus (x)
CN
Contract/Business
Cases D12 Dissolution of a Partnership E22 Lottery Assignment, G.L. c. 10, § 28 (x)
D13 Declaratory Judgment, G.L. ¢. 2314 A
A01 Services, Labor, and Materials (F) D14 Dissolution of a Corporation F) AB Abuse/Harassment Prevention
A02 Goods Sold and Delivered (F) D99 Other Equity Action (F)
A03 Commercial Paper (F) E15 Abuse Prevention Petition, G.L. c. 209A _(X)
A04 Employment Contract (F) PA Civil Actions Involving Incarcerated
Party + E21 Protection from Harassment, G.L. c. 258E(X)
A05 Consumer Revolving Credit - MR.cP.at (F)
A06 Insurance Contract (F) PA1 Contract Action involving an AA imini ivil ns
A08 Sale or Lease of Real Estate (F) Incarcerated Party
A112 Construction Dispute (A) A) E02 Appeal from Administrative Agency,
14 Interpleader PB1 Tortious Action involving an G.L.c. 30A
(F) Incarcerated Party (Xx)
BA1 Governance, Conduct, Internal A) E03 Certiorari Action, G. ©. 249, §4 (x)
Affairs of Entities PC1 Real Property Action involving an E05 Confirmation of Arbitration Awards
(A) Incarcerated Party (Xx)
BAS Liability of Shareholders, Directors, (F) E06 Mass Antitrust Act, G.L. c. 93, § 9 (A)
Officers, Partners, etc. PD1 Equity Action involving an E07 Mass Antitrust Act, G.L. c. 93, § 8
(A) Incarcerated Party (Xx)
BB1 Shareholder Derivative (A) (F) E08 Appointment of a Receiver (x)
BB2 Securities Transactions PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. c. 149,
(A) Incarcerated Party
BC1 Mergers, Consolidations, Sales of (F) § 29, 298, (A)
Assets, Issuance of Debt, Equity, ete. (A) E10 Summary Process Appeal (x)
BD1 Intellectual Property (A) TR Torts. E11 Worker's Compensation (x)
BD2 Proprietary Information or Trade B03 Motor Vehicle Negligence - Personal E16 Auto Surcharge Appeal (x)
Secrets (A) Injury/Property Damage E17 Civil Rights Act, G.L. .12, § 11H (A)
BG1 Financial Institutions/Funds (A) (F) E24 Appeal from District Court
BH1 Violation of Antitrust or Trade B04 Other Negligence - Personal Commitment, G.L. c.123, § 9(b) (x)
Regulation Laws Injury/Property Damage (F) E25 Pleural Registry (Asbestos cases)
(A) B05 Products Liability (A)
A99 Other Contract/Business Action - Specify (F) E94 Forfeiture, G.L. c. 265, § 56 (x)
B06 Malpractice - Medical A) E96 Forfeiture, G.L. c. 94C, § 47 (F)
B07 Malpractice - Other (A) E99 Other Administrative Action
B08 Wrongful Death - Non-medical (x)
* Choose this case type if ANY party is the (A) Z01 Medical Malpractice - Tribunal only,
‘Commonwealth, a municipality, the MBTA, or any B15 Defamation (A) .¢. 231,
§ 608
other governmental entity UNLESS your case is a B19 Asbestos (a) Z02 Appeal Bond Denial
(F)
(x)
case type listed under Administrative Civil Actions B20 Personal Injury - Slip & Fall (F)
(AA). B21 Environmental (F) x ni view
B22 Employment Discrimination (F)
+ Choose this case type if ANY party is an BE1 Fraud, Business Torts, etc. (a) E12 SDP Commitment, G.L. c. 123A, § 12 (x)
incarcerated party, UNLESS your case is a case B99 Other Tortious Action (F) E14 SDP Petition, G.L. c. 123A, § 9(b) (x)
type listed under Administrative Civil Actions (AA)
or is a Prisoner Habeas Corpus case (E97). P Summary Process (Real Property). RC
Restricted
Civil Actions
$01 Summary Process - Resiciential ~ E19 Sex Offender Registry, G.L. c. 6, § 178M (X)
$02 Summary Process - Commercial E27 Minor Seeking Consent, G.L. ¢.112, § 128(X)
Non-residential (F)
TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
{X] Yes NO
Bo3 Motor Vehicle Negligence-Personal Injury Ff.
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.
Preview
DOCKET NUMBER Trial Court of Massachusetts CIVIL ACTION COVER SHEET The Superior Court PLAINTIFF(S): Lorin P. Burrows |COUNTY ADDRESS: 20 Dowds Lane. Princeton, MA 01541 Worcester DEFENDANT(S): Janet L. Cassidy, 109 S. Main Street, Millbury, MA 01527 ATTORNEY: Gregory W. Wheeler ADDRESS: 15 Monument Sq., Suite 225, Leominster, MA ADDRESS: 01453 BBO: 669202 TYPE OF ACTION AND TRACK DESIGNATION (see reverse side) CODE NO. TYPE OF ACTION (specify) Cl HAS A JURY CLAIM BEEN MADE? A99 & D13 Breach of Fiduciary Duty of Trustee F (Yes 0 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? YES NO YES NO 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 plaintiffs counsel relies to determine money damages. For this form, disregard double or treble damage claims; indicate single damages only. ‘(ORT CLAIMS (attach additional sheets as necessary) . 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 b Subtotal (A): . Documented lost wages and compensation to date . . Documented property damages to date ..... . Reasonably anticipated future medical and hospital expense: . Reasonably anticipated lost wages ..... . Other documented items of damages (describe below) IG. Briefly describe plaintiff's injury, including the nature and extent of injury: TOTAL (A-F):$ (attach additional sheets as necessary) [1 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): Defendant has failed to administer irrevocable trust according to its terms. TOTAL: $ Plaintiff seeks to enforce the terms of the Trust and to recover damages equivalent to benefits he reasonably eynected to receive Plaintiff alen ceeks declaratory and ininnetive relief Signature of Attorney/ Unrepresented Plaintiff: X Date: 12/2/2020 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 ladvantages and disadvantages of the various methods of dispute resolution. a Ne 12/2/2020 Signature of Attorney of Record: X Date: CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE Acti Involvin, Municii * R Equitable Remedies. Real Property ‘AA1 Contract Action involving Commonwealth, D01 Specific Performance of a Contract (A) 01 Land Taking (F) Municipality, MBTA, etc. (A) Do2 Reach and Apply (F) C02 Zoning Appeal, G.L. c. 408 (F) AB1 Tortious Action involving Commonwealth, 03 Injunction (F) C03 Dispute Concerning Title (F) Municipality, MBTA, etc. (A) D04 Reform/ Cancel Instrument () C04 Foreclosure of a Mortgage (Xx) AC1 Real Property Action involving DO5 Equitable Replevin (F) COS Condominium Lien & Charges (x) Commonwealth, Municipality, MBTA etc. (A) D06 Contribution or Indemnification (F) C99 Other Real Property Action (F) AD1 Equi Action involving Commonwealth, DO7 Imposition of a Trust (A) Municipality, MBTA, etc. (A) Do8 Minority Shareholder's Suit (A) -MC Miscellaneous Civil Actions ‘AE1 Administrative Action involving D9 Interference in Contractual Relationship (F) Commonwealth, Municipality, MBTA,etc. (A) D10 Accounting (A) E18 Foreign Discovery Proceeding (x) D114 Enforcement of Restrictive Covenant (F) E97 Prisoner Habeas Corpus (x) CN Contract/Business Cases D12 Dissolution of a Partnership E22 Lottery Assignment, G.L. c. 10, § 28 (x) D13 Declaratory Judgment, G.L. ¢. 2314 A A01 Services, Labor, and Materials (F) D14 Dissolution of a Corporation F) AB Abuse/Harassment Prevention A02 Goods Sold and Delivered (F) D99 Other Equity Action (F) A03 Commercial Paper (F) E15 Abuse Prevention Petition, G.L. c. 209A _(X) A04 Employment Contract (F) PA Civil Actions Involving Incarcerated Party + E21 Protection from Harassment, G.L. c. 258E(X) A05 Consumer Revolving Credit - MR.cP.at (F) A06 Insurance Contract (F) PA1 Contract Action involving an AA imini ivil ns A08 Sale or Lease of Real Estate (F) Incarcerated Party A112 Construction Dispute (A) A) E02 Appeal from Administrative Agency, 14 Interpleader PB1 Tortious Action involving an G.L.c. 30A (F) Incarcerated Party (Xx) BA1 Governance, Conduct, Internal A) E03 Certiorari Action, G. ©. 249, §4 (x) Affairs of Entities PC1 Real Property Action involving an E05 Confirmation of Arbitration Awards (A) Incarcerated Party (Xx) BAS Liability of Shareholders, Directors, (F) E06 Mass Antitrust Act, G.L. c. 93, § 9 (A) Officers, Partners, etc. PD1 Equity Action involving an E07 Mass Antitrust Act, G.L. c. 93, § 8 (A) Incarcerated Party (Xx) BB1 Shareholder Derivative (A) (F) E08 Appointment of a Receiver (x) BB2 Securities Transactions PE1 Administrative Action involving an E09 Construction Surety Bond, G.L. c. 149, (A) Incarcerated Party BC1 Mergers, Consolidations, Sales of (F) § 29, 298, (A) Assets, Issuance of Debt, Equity, ete. (A) E10 Summary Process Appeal (x) BD1 Intellectual Property (A) TR Torts. E11 Worker's Compensation (x) BD2 Proprietary Information or Trade B03 Motor Vehicle Negligence - Personal E16 Auto Surcharge Appeal (x) Secrets (A) Injury/Property Damage E17 Civil Rights Act, G.L. .12, § 11H (A) BG1 Financial Institutions/Funds (A) (F) E24 Appeal from District Court BH1 Violation of Antitrust or Trade B04 Other Negligence - Personal Commitment, G.L. c.123, § 9(b) (x) Regulation Laws Injury/Property Damage (F) E25 Pleural Registry (Asbestos cases) (A) B05 Products Liability (A) A99 Other Contract/Business Action - Specify (F) E94 Forfeiture, G.L. c. 265, § 56 (x) B06 Malpractice - Medical A) E96 Forfeiture, G.L. c. 94C, § 47 (F) B07 Malpractice - Other (A) E99 Other Administrative Action B08 Wrongful Death - Non-medical (x) * Choose this case type if ANY party is the (A) Z01 Medical Malpractice - Tribunal only, ‘Commonwealth, a municipality, the MBTA, or any B15 Defamation (A) .¢. 231, § 608 other governmental entity UNLESS your case is a B19 Asbestos (a) Z02 Appeal Bond Denial (F) (x) case type listed under Administrative Civil Actions B20 Personal Injury - Slip & Fall (F) (AA). B21 Environmental (F) x ni view B22 Employment Discrimination (F) + Choose this case type if ANY party is an BE1 Fraud, Business Torts, etc. (a) E12 SDP Commitment, G.L. c. 123A, § 12 (x) incarcerated party, UNLESS your case is a case B99 Other Tortious Action (F) E14 SDP Petition, G.L. c. 123A, § 9(b) (x) type listed under Administrative Civil Actions (AA) or is a Prisoner Habeas Corpus case (E97). P Summary Process (Real Property). RC Restricted Civil Actions $01 Summary Process - Resiciential ~ E19 Sex Offender Registry, G.L. c. 6, § 178M (X) $02 Summary Process - Commercial E27 Minor Seeking Consent, G.L. ¢.112, § 128(X) Non-residential (F) TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? {X] Yes NO Bo3 Motor Vehicle Negligence-Personal Injury Ff. 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.