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o l T l Tri � urt IfMassachus tts
<br /> CIVIL!ACTION COVER SHEET The Superior Court
<br /> PLAINTIFF($): WIliam R.Haney and Mary E.Zocchi COUNTY
<br /> ADDRESS: $40 Great Nerds Road South,Mashpoo,MA 02649
<br /> DEFER DAINT#!5): Ma3hpeo ZonlM Doord of Appeals
<br /> ATTORNEY,. Srlat,F.-Vyall,Esq.
<br /> ADDRESS: -00 Route Ok Sandwich,MA 02503 ADDRESS: 16 Great Neck Road North,Mashpee,MA 02049
<br /> EBO: 66006D
<br /> TYPE OF ACTION AND TRACK DESIGNATION(soo rovdrso side)
<br /> CODE NO, TYPE OF ACTION{speolfy) TRACK HAS A JURY CLAIM BEEN MADE?
<br /> CO2 Zoning Appeal,G,L,c.40A,s.17 F YES NO
<br /> V 110thor"plcase describe:
<br /> STATEMENT OF DAMAGES PURSUANT TO G.L.c.212, 3A
<br /> The following Is a full,Itemized and detailed staterneni'of the facts en vvh1oh jh0 underslgned plaintiff or piaintl ff counsel reties to deterrhine money damages. For
<br /> this fornh,disregard d.oubte'er treble damage clalms;Indicate single damn'ges only,
<br /> TAT CLAIM$
<br /> (attach-additional�hiWs as-necessary)
<br /> A.Documented medical expenses to date!:
<br /> I.Total hospital expenses
<br /> Total. ■/y� iy�,11-{/���s+ �y1 ��{+ Ilii++1114111+11ir.if,lrlrY.ii9.1+9...79.i1v1M�lTT**••1••*••••••vTTri vrTTr••+Iv•+++++�}}aa7rr}rl.+.r.91ri.►1•..1.F..r1r1l1IFr111i*.171 Tr.rev 8111•*�Tv*•rT•••v+rel
<br /> 2, total doctor xpen�OS............101 a-10%lry 111411•*4+-11111+ii++iir++Looe.•I I Niel 1117./11Pool 11��F1+11q.1811.g1ely.%1l11ff4f1'a+irR 1+itai1111 a 1+410bod4liiaiirl l...l+a li r\..+i 81,141 I+.IFI Al
<br /> 3+Total.
<br /> chlroFptactleexpew*,yses�y+*+4q•1•j+++11�11i.ia111181.ra181.F.1111..1}ff1v1!!l11•1.iri.lPIN�,1818+I+f 1-1 l+i•+•+a a.11f'1,1.../111,1..1rf8.F►I1.IIIJ.F.1.I1.,1.F1911.1FIrl l7r1T111111T!!!!fr
<br /> 4. }otal.physical therapy i$XpenftS rF.l I i r I11T*r1+•v!•••q{...i++ailiil+++61Ji 11,111,1.+,1,1 Y 1+I p 1 Y Y r.r 11.1 I I i 11 r v 1 r 1111.11*T++YI••++1.1}.i}+++.F++•.i1++144&b&i+i 4 i s.1-,+11/a•.1410A Y.}11Y IE
<br /> rr� ■J•L�J��1 other
<br /> expenses-
<br /> yY�� �r'.y! ,�•i.] {/�1� �1••�.below)
<br /> 5.Total other xpens s-(describe belo )+I r+.1 11•Y Y r 11 r r►.1 i 1 1 F 1 r-11+*4*111111+.11 r 111 i 1*r 111••1 T I+Ai Y l l iiff 164 11 Y.I ti l re lA 94%d1611.1111'I1y 161 1$F8.+v.11 r 11 I r YF r T l 111 l F T 1 r I 1-0111 $ -................ ..... .... -
<br /> Subtotal(A).- $
<br /> 13*Documented.lost wr{].7g�r+er+{ .Fa�y�nd compensation
<br /> `ion to date+1++•1-..r.1..rj r r'•441111-1 I,T*.,1 811 vr4}rFl.rlr+19 TT*ry 9-v-vl+r+•1}}1*4 oG6 f r r.Y...r..I I I..1-•i 7.i-voI,.I.rel 71F!119 fT++•ry I e**P+v9-r••
<br /> C.Documented property damages dyed■...I 11.�I11I1 v**i•�{1}1+}..11++...111*0401 vaa�,11•..I,1144}.i/941F1.111F..11111 111!*!\I 1106hk 10 lffi•1+11+a..141-1111..+...111.1 r 941EMPI 19 I1.F1/fY18r17,1■ $
<br /> DT Reasonably a777nRticlip/altfffYetd 1Ffut rewages
<br /> medical and hosplIai expenses 11,1111*T•!1•I IT•••i.{1•F+••.Y+..ii.+!ii 4164 b1.ai r..1.•119!1.11101-f.I1611P TT•11r f 1-T 1181 I•T 199 F.I...•••+•+.f..i i+1+F 1�
<br /> E.Reasonably anR 1pated lost'iag.Y},i1f 1.F1A�.......}r.............1•11��P P{Iyr,+11-,11+•}�.i 4.I.111i4 1...I1.FF11191,11,188►9 I.,1 4F.V 1.I l i.1.....iT•••I.iii..lriY.I1Y.YYYF...6 Nar.!1-f ril l.e}.Ii F.►r 4 1111 Y 11.i 11}!F1•i 7119
<br /> F.Other docu■rnented items of damages(describe below).I1.1Y......
<br /> G,Briefly describe plairtliffs Injory,including the nature and extent of-Injury;
<br /> TOTAL(A-P):$
<br /> �I.
<br /> (attach additional shae�t�as necessary)
<br /> Provide a delalled de5cflplion.of clalrns(s);
<br /> TOTAL:�
<br /> Signature of Attorney/Pro So Plaintlf€:X Date:
<br /> RELATED ACTIONS:Please provide the oase number,case name,and county of any related actions pending in the Superior-C1Vu L7
<br /> CERTIFICATION.,PURSUANT TO SJC RULE 1:18
<br /> I hereby certify that I have complied with require-tments of Rule 5 of the Supreme Jud lcisI Court Uniform Rules on Dispute Resolution(SJC
<br /> Rule 1:15)requiring that I provide my clients with Information about court ecnnected dispute resonation services and discuss with there the
<br /> advantages,arld disddvantages of the various met p isputresolution.
<br /> Signature of Attorney.of Record; X Date: 12/20/18
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