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DOCKET NUMBER Trial Court of Massachusetts <br /> CIVIL ACTION COVER SHEET ),_2 The Superior Court <br /> COUNTY <br /> PLAINTIFF(S); Katherine McBrien Barnstable <br /> ADDRESS: 37 Center Street,Mashpee,MA.02649 <br /> DEPENDANT(S): Furbush et al.as the Mashpee Zoning Board of Appeal <br /> ATTORNEY: Paul Revere,III <br /> ADDRESS: 226 River View Lane,Centerville,MA.02632 ADDRESS: <br /> 16 Great Neck Road,South,Mashpee,MA 02649 <br /> BBO: 636200 <br /> TYPE OF ACTION AND TRACK DESIGNATION(see reverse side) <br /> CODE NO. TYPE OF ACTION(specify) TRACK HAS A JURY CLAIM BEEN MADE? <br /> CO2 Zoning Appeal-G.L.ch,40A F YES NO <br /> *If"Other'please describe: <br /> STATEMENT OF DAMAGES PURSUANT TO G.L.c.212,§3A <br /> 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 <br /> this form,disregard double or treble damage claims;Indicate single damages gnly. <br /> TORT CLAIMS <br /> (attach additional sheets as necessary) <br /> A.Documented medical expenses to date: $ <br /> 1.Total hospital expenses.................. ............................................................................................................................................ $ <br /> 2.Total doctor expenses................................................................................................................................................................... $ <br /> 3.Total chiropractic expenses........................................................................................................................................................... <br /> 4.Total physical therapy expenses......................................................................._......................_..........................................._........ $ <br /> describe below).................................................................................................................. <br /> 5.Total other expenses . . $ <br /> R ( . Subtotal(A): $ -Ig1FL.. <br /> $ NIA <br /> B.Documented lost wages and compensation to date.................................................................................................................. .. $ NIA <br /> C.Documented property damages to dated..................................................._......._......................_........._..................._....................._._.......... <br /> D.Reasonably anticipated future medical and hospital expenses................................................................................................................... $ <br /> $ N1A <br /> E.Reasonably anticipated lost wages...................................................................................................................................................................... $ ..�- <br /> F.Other documented items of damages(describe below .............................. <br /> .......................................................................................... <br /> G.Briefly describe plaintifrs injury,including the nature and extent of injury: <br /> TOTAL(A-F):$ NIA <br /> CONTRACT CL W5 <br /> (attach additional sheets as necessary) <br /> Provide a detailed description of claims(s): TOTAL:$ wA <br /> Signature of Attorney/Pro Se Plaintiff:X --- Date. 81912017 <br /> RELATED ACTIONS: Please provide the case number,case name, and county of any related actions pending in the Superior Court. <br /> CERTIFICATION PURSUANT TO SJC RULE 1:18 <br /> 1 hereby certify that I have complied with requirements of Rule 5 of the Supreme Judicial Court Uniform Rules on Dispute Resolution(SJC <br /> Rule 1:18)requiring that I provide my clients with information about court-connected dispute resolution services and discuss with them the <br /> advantages and disadvantages of the various methocl?W e-M <br /> Signature of Attorney of Record: X Date: 819/2017 <br />