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f <br /> DOCKET NU�IIB R Trial Court of Massachusetts <br /> CIVIL ACTION COVER SHEET -7- cJ-. j The Superior Court <br /> PLAINTIFF(S). Katherine McBrien COUNTY <br /> Barnstable <br /> ADDRESS: 37 Center Sireet,Mashpee,MA.02649 <br /> DEFENDANT(S): Furbush at 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,SocAh,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 QX 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 /> 5.Total other expenses(describe below)........................................................................................................... ........................... $ <br /> Subtotal(A): $ <br /> B.Documented last wages and compensation to date........................ .......... $ N/A <br /> C.Documented property damages to dated...................................................................................................................................................... $ N/A <br /> D.Reasonably anticipated future medical and hospital expenses.............. $ T <br /> E.Reasonably anticipated lost wages............................................................................................................................................................. $ NIA <br /> F.Other documented items of damages(describe below) ... $ � <br /> G.Briefly describe plaintiffs injury,including the nature and extent of injury: <br /> TOTAL(A-F):$ NIA <br /> CONTRACT CLAIMS <br /> (attach additional sheets as necessary) <br /> Provide a detailed description of claims(s): <br /> TOTAL:$ NIA <br /> Signature of Attorney/Pro Se Plaintiff:X Date: 8/9/2017 <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 /> I 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 methods€dutee <br /> Signature of Attorney of Record: X '�� Date: 8/9/2017 <br />