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DOCKET NUMBER Trial Court of Massachusetts —
CIVIL ACTION COVER SHEET The Superior Court
PLAINTIFF(S): Endl Luc COUNTY
TT Middlesex
ADDRESS: 25 Buttrick Road, #D2
Londonderry, NH 03053, DEFENDANT(S): The Woods, LLC
ATTORNEY: Kevin G. Collimore, Esquire
ADDRESS: CullenCollimore, plic ADDRESS: 199 Salem Street
10 East Pearl Street Wakefield, MA 01880.
Nashua, NH 03060
BBO: 632179
TYPE OF ACTION AND TRACK DESIGNATION (see reverse side)
CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE?
Ao1 Services, Labor and Materials F Cl yes
*If "Other" please describe:
Is there a claim under G.L. c. 93? Is this a class action under Mass. R. Civ. P. 23?
LI Yes CJ Yes
STATEMENT OF DAMAGES PURSUANT TO GL. c. 212, § 3A
IThe 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)
lA. 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)
RECEIVED
. Documented lost wages and compensation to date
. Documented property damages to date ...
. Reasonably anticipated future medical and hospital expenses
. Reasonably anticipated lost wages ....
. Other documented items of damages (describe below) ....
aMmoOO w
IG. Briefly describe plaintiff's injury, including the nature and extent of injury:
TOTAL (A-F):$
(attach additional sheets as necessary)
oO 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: $ 75,000+
Unpaid debt arising from Plaintiff's environmental consulting services, plus contractual interest and collection costs.
Signature of Attorney/ Unrepresented Plaintiff: X /s/ Kevin G. Collimore Date: 02/01/2021
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.
Signature of Attorney of Record: X /s/ Kevin G. Collimore Date: 02/01/2021CIVIL ACTION COVER SHEET INSTRUCTIONS
SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE
Actions Involvin. Municipality *
‘AA1 Contract Action involving Commonwealth,
Municipality, MBTA, etc. a)
AB1 Tortious Action involving Commonwealth,
Municipality, MBTA, etc. A)
C1 Real Property Action involving
Commonwealth, Municipality, MBTA etc. (A)
AD1 Eauity Action involving Commonwealth,
Municipality, MBTA, etc. a)
AE1 Administrative Action involving
Commonwealth, Municipality, MBTA,etc. (A)
CN Contract/Business Cases.
01 Services, Labor, and Materials (F)
A02 Goods Sold and Delivered ()
A03 Commercial Paper (F)
A04 Employment Contract (F)
‘A0S Consumer Revolving Credit-mrcr.e1 (F)
A06 Insurance Contract (F)
A08 Sale or Lease of Real Estate ()
A12 Construction Dispute (A)
A14 Interpleader (F)
BA{ Governance, Conduct, Internal
Affairs of Entities (A)
BAS Liability of Shareholders, Directors,
Officers, Partners, etc. (A)
BB1 Shareholder Derivative (A)
BB2 Securities Transactions (a)
BC1 Mergers, Consolidations, Sales of
Assets, Issuance of Debt, Equity, etc. (A)
BD1 intellectual Property a)
BD2 Proprietary Information or Trade
Secrets (A)
BG1 Financial Institutions/Funds a)
BH1 Violation of Antitrust or Trade
Regulation Laws a)
A99 Other Contract/Business Action - Specify (F)
* Choose this case type if ANY patty is the
‘Commonwealth, a municipality, the MBTA, or any
other governmental entity UNLESS your case is a
case type listed under Administrative Civil Actions
(AA).
+ Choose this case type if ANY party is an
incarcerated party, UNLESS your case is a case
type listed under Administrative Civil Actions (AA)
or is a Prisoner Habeas Corpus case (E97).
ER Equitable Remedies
DO1 Specific Performance of a Contract (A)
D02 Reach and Apply (F)
03 Injunction (F)
D04 Reform/ Cancel Instrument (F)
DOS Eauitable Replevin (F)
DO6 Contribution or indemnification (F)
DO7 Imposition of a Trust (a)
08 Minority Shareholder's Suit (A)
DO9 Interference in Contractual Relationship (F)
D10 Accounting (A)
D11 Enforcement of Restrictive Covenant —(F)
12 Dissolution of a Partnership (F)
D13 Dedaratory Judgment, G.l.c.231A (A)
14 Dissolution of a Corporation (F)
D99 Other Equity Action (F)
PA Civil Actions Involving Incarcerated Party +
PA1 Contract Action involving an
Incarcerated Party A)
PB1 Tortious Action involving an
Incarcerated Party (A)
PC1 Real Propetty Action involving an
Incarcerated Party (Fy
PD1 Equity Action involving an
Incarcerated Party (Fy
PE1 Administrative Action involving an
Incarcerated Party (Fy
TR Torts.
B03 Motor Vehicle Negligence - Personal
Injury/Property Damage (F)
B04 Other Negligence - Personal
Injury/Property Damage (F)
BOS Products Liability (A)
B06 Malpractice - Medical (A)
BO7 Malpractice - Other A)
B08 Wrongful Death - Non-medical (A)
B15 Defamation (A)
B19 Asbestos (A)
B20 Personal Injury - Slip & Fall (F)
B21 Environmental (F)
B22 Employment Discrimination (F)
BE1 Fraud, Business Torts, etc. (A)
B99 Other Tortious Action (F)
RP Summary Pr Pr
S01 Summary Process - Residential ~
$02 Summary Process - Commercial
Non-residential (F)
TRANSFER YOUR SELECTION TO THE FACE SHEET
EXAMPLE:
CODE NO. TYPE OF ACTION (specify) TRACK
Bo3 Motor Vehicle Negligence-Personal Injury E
RP Real Pr
C01 Land Taking (F)
C02 Zoning Appeal, G.L. c. 408 (F)
C03 Dispute Concerning Title )
C04 Foreclosure of a Mortgage )
COS Condominium Lien & Charges )
C99 Other Real Property Action (F)
Mi ‘vil Acti
E18 Foreign Discovery Proceeding (x)
E97 Prisoner Habeas Corpus ®)
E22 Lottery Assignment, G.L.c.10,§28 — (X)
AB Abuse/Harassment Prevention
E15 Abuse Prevention Petition, G.L. c. 209A _(X)
E21 Protection from Harassment, G.L. c. 258E(X)
AA Administrative Civil Action:
E02 Appeal from Administrative Agency,
G.L.c. 30A %)
E03 Certiorari Action, G.L. ¢. 249, § 4 x)
E05 Confirmation of Arbitration Awards )
E06 Mass Antitrust Act, G.L. c. 93, § 9 a)
E07 Mass Antitrust Act, G.L. c. 93, § 8 )
E08 Appointment of a Receiver &)
E09 Construction Surety Bond, G.L. c. 149,
§§ 29, 290, (A)
E10 Summary Process Appeal (%)
E11 Worker's Compensation (x)
E16 Auto Surcharge Appeal )
E17 Civil Rights Act, G.L. c.12, § 11H (A)
E24 Appeal from District Court
Commitment, G.L. .123, § 9b) (x)
E25 Pleural Registry (Asbestos cases)
E94 Forfeiture, G.L. c. 265, § 56 ~
E95 Forfeiture, G.L. c. 94C, § 47 ()
E99 Other Administrative Action )
Z01 Medical Malpractice - Tribunal only,
GL. c. 231, § 608 (F)
202 Appeal Bond Denial (x)
x Offender Review
E12 SDP Commitment, G.L. c. 123A, § 12 (X)
E14 SDP Petition, G.L. c. 123A, § 9(b) *)
RC Restricted Civil Acti
E19 Sex Offender Registry, G.L. ¢. 6, § 178M (X)
E27 Minor Seeking Consent, G.L. ¢.112, § 128(X)
HAS A JURY CLAIM BEEN MADE?
[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), 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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DOCKET NUMBER Trial Court of Massachusetts — CIVIL ACTION COVER SHEET The Superior Court PLAINTIFF(S): Endl Luc COUNTY TT Middlesex ADDRESS: 25 Buttrick Road, #D2 Londonderry, NH 03053, DEFENDANT(S): The Woods, LLC ATTORNEY: Kevin G. Collimore, Esquire ADDRESS: CullenCollimore, plic ADDRESS: 199 Salem Street 10 East Pearl Street Wakefield, MA 01880. Nashua, NH 03060 BBO: 632179 TYPE OF ACTION AND TRACK DESIGNATION (see reverse side) CODE NO. TYPE OF ACTION (specify) TRACK HAS A JURY CLAIM BEEN MADE? Ao1 Services, Labor and Materials F Cl yes *If "Other" please describe: Is there a claim under G.L. c. 93? Is this a class action under Mass. R. Civ. P. 23? LI Yes CJ Yes STATEMENT OF DAMAGES PURSUANT TO GL. c. 212, § 3A IThe 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) lA. 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) RECEIVED . Documented lost wages and compensation to date . Documented property damages to date ... . Reasonably anticipated future medical and hospital expenses . Reasonably anticipated lost wages .... . Other documented items of damages (describe below) .... aMmoOO w IG. Briefly describe plaintiff's injury, including the nature and extent of injury: TOTAL (A-F):$ (attach additional sheets as necessary) oO 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: $ 75,000+ Unpaid debt arising from Plaintiff's environmental consulting services, plus contractual interest and collection costs. Signature of Attorney/ Unrepresented Plaintiff: X /s/ Kevin G. Collimore Date: 02/01/2021 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. Signature of Attorney of Record: X /s/ Kevin G. Collimore Date: 02/01/2021CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE Actions Involvin. Municipality * ‘AA1 Contract Action involving Commonwealth, Municipality, MBTA, etc. a) AB1 Tortious Action involving Commonwealth, Municipality, MBTA, etc. A) C1 Real Property Action involving Commonwealth, Municipality, MBTA etc. (A) AD1 Eauity Action involving Commonwealth, Municipality, MBTA, etc. a) AE1 Administrative Action involving Commonwealth, Municipality, MBTA,etc. (A) CN Contract/Business Cases. 01 Services, Labor, and Materials (F) A02 Goods Sold and Delivered () A03 Commercial Paper (F) A04 Employment Contract (F) ‘A0S Consumer Revolving Credit-mrcr.e1 (F) A06 Insurance Contract (F) A08 Sale or Lease of Real Estate () A12 Construction Dispute (A) A14 Interpleader (F) BA{ Governance, Conduct, Internal Affairs of Entities (A) BAS Liability of Shareholders, Directors, Officers, Partners, etc. (A) BB1 Shareholder Derivative (A) BB2 Securities Transactions (a) BC1 Mergers, Consolidations, Sales of Assets, Issuance of Debt, Equity, etc. (A) BD1 intellectual Property a) BD2 Proprietary Information or Trade Secrets (A) BG1 Financial Institutions/Funds a) BH1 Violation of Antitrust or Trade Regulation Laws a) A99 Other Contract/Business Action - Specify (F) * Choose this case type if ANY patty is the ‘Commonwealth, a municipality, the MBTA, or any other governmental entity UNLESS your case is a case type listed under Administrative Civil Actions (AA). + Choose this case type if ANY party is an incarcerated party, UNLESS your case is a case type listed under Administrative Civil Actions (AA) or is a Prisoner Habeas Corpus case (E97). ER Equitable Remedies DO1 Specific Performance of a Contract (A) D02 Reach and Apply (F) 03 Injunction (F) D04 Reform/ Cancel Instrument (F) DOS Eauitable Replevin (F) DO6 Contribution or indemnification (F) DO7 Imposition of a Trust (a) 08 Minority Shareholder's Suit (A) DO9 Interference in Contractual Relationship (F) D10 Accounting (A) D11 Enforcement of Restrictive Covenant —(F) 12 Dissolution of a Partnership (F) D13 Dedaratory Judgment, G.l.c.231A (A) 14 Dissolution of a Corporation (F) D99 Other Equity Action (F) PA Civil Actions Involving Incarcerated Party + PA1 Contract Action involving an Incarcerated Party A) PB1 Tortious Action involving an Incarcerated Party (A) PC1 Real Propetty Action involving an Incarcerated Party (Fy PD1 Equity Action involving an Incarcerated Party (Fy PE1 Administrative Action involving an Incarcerated Party (Fy TR Torts. B03 Motor Vehicle Negligence - Personal Injury/Property Damage (F) B04 Other Negligence - Personal Injury/Property Damage (F) BOS Products Liability (A) B06 Malpractice - Medical (A) BO7 Malpractice - Other A) B08 Wrongful Death - Non-medical (A) B15 Defamation (A) B19 Asbestos (A) B20 Personal Injury - Slip & Fall (F) B21 Environmental (F) B22 Employment Discrimination (F) BE1 Fraud, Business Torts, etc. (A) B99 Other Tortious Action (F) RP Summary Pr Pr S01 Summary Process - Residential ~ $02 Summary Process - Commercial Non-residential (F) TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO. TYPE OF ACTION (specify) TRACK Bo3 Motor Vehicle Negligence-Personal Injury E RP Real Pr C01 Land Taking (F) C02 Zoning Appeal, G.L. c. 408 (F) C03 Dispute Concerning Title ) C04 Foreclosure of a Mortgage ) COS Condominium Lien & Charges ) C99 Other Real Property Action (F) Mi ‘vil Acti E18 Foreign Discovery Proceeding (x) E97 Prisoner Habeas Corpus ®) E22 Lottery Assignment, G.L.c.10,§28 — (X) AB Abuse/Harassment Prevention E15 Abuse Prevention Petition, G.L. c. 209A _(X) E21 Protection from Harassment, G.L. c. 258E(X) AA Administrative Civil Action: E02 Appeal from Administrative Agency, G.L.c. 30A %) E03 Certiorari Action, G.L. ¢. 249, § 4 x) E05 Confirmation of Arbitration Awards ) E06 Mass Antitrust Act, G.L. c. 93, § 9 a) E07 Mass Antitrust Act, G.L. c. 93, § 8 ) E08 Appointment of a Receiver &) E09 Construction Surety Bond, G.L. c. 149, §§ 29, 290, (A) E10 Summary Process Appeal (%) E11 Worker's Compensation (x) E16 Auto Surcharge Appeal ) E17 Civil Rights Act, G.L. c.12, § 11H (A) E24 Appeal from District Court Commitment, G.L. .123, § 9b) (x) E25 Pleural Registry (Asbestos cases) E94 Forfeiture, G.L. c. 265, § 56 ~ E95 Forfeiture, G.L. c. 94C, § 47 () E99 Other Administrative Action ) Z01 Medical Malpractice - Tribunal only, GL. c. 231, § 608 (F) 202 Appeal Bond Denial (x) x Offender Review E12 SDP Commitment, G.L. c. 123A, § 12 (X) E14 SDP Petition, G.L. c. 123A, § 9(b) *) RC Restricted Civil Acti E19 Sex Offender Registry, G.L. ¢. 6, § 178M (X) E27 Minor Seeking Consent, G.L. ¢.112, § 128(X) HAS A JURY CLAIM BEEN MADE? [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), 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.