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DOCKETNUMBER Trial Court of Massachusetts <br /> CIVIL ACTION COVER SHEET The Superior Court <br /> FLWNTIFFlsl; MatttuiwHanoy,Trusteaotthe Gooseberry Island Trust,and COUNTY <br /> ADDRESS: Malumm Hanay,Tmsloe of lho SNTRust <br /> P.O.Sox 1416.Broakthe MA02446 DEMDANTISI: Mashpee Toning Board of Appeals <br /> ATTORNEY: ad"J.WWI.Esq. <br /> ADDRESS: go Mute 9A,SWKWch,MAD2363 ADDRESS: Meshpao Town Hall,18 Groat Neck Road North,Mashpao MA 42849 <br /> BaO: 66DM <br /> TYPE OF ACTION AND TRACK DESIGNATION(see reverse side) <br /> CODE NO. TYPE OF ACTION(spocify) TRACK HAS A JURY CLAIM BEEN MADE? <br /> Cat' Zontng Appeal,.O.L 40A F n YES []X NO <br /> 'if"Other"please describo: <br /> Is there a claim tender G.L.c.93A? to this a class action under Mass.R.Civ.P.231 <br /> YES Q NO 0 YES Q NO <br /> STATEMENT OF DAMAGES PURSUANT TO G.L.c.212,6 3A <br /> 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. <br /> For this form,disregard double or treble damage claims;Indicate single damagewonly. <br /> ( <br /> A Documented medical expanses to data: attach additional sheets as necessary) <br /> 1.Total hospital expenses................................................................................................................................................................. S <br /> 2.Total doctor expenses............................................................................................................. s <br /> 3.Total chiropractic expenses. ........................................ ......................................................................................................... $ <br /> A.Total physical therapy expenses.................................................................................................................... ............................. g .. <br /> S.Total other expenses(describe befow)...................................................................................................................... � <br /> Subiotal(Ay s <br /> B.Documented lost wages and compensation to date........................................................,,...,.................:...................................................... S. <br /> C.Documented property damages to date...................................................................................................................................................... S <br /> D.Reasonably anticipated future madical and hospital expenses.............................................................................. <br /> ...................................... <br /> E.Reasonably anticipated lost wages.........................................................................................................................................................�.... <br /> F.Other documented items of damages(describe below)........................................................................ <br /> G.Briefly describe plalntiffe Injury,Including the nature and extent of Injury. <br /> TOTAL(A-F).4 <br /> CONTRA01 CLAIMS <br /> (attach additional ahttels as necessary) <br /> ❑This action lnctudes a clalm involving Collection of a debt incurred pursuant to a revolving credit agreement.!Nass.R,Civ.P.8.1(a). <br /> Provlde a detailed description of claim(s): <br /> TOTAL;$ <br /> Signature of Attorney!Unrepresented Plaintiff:X Date. <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#hat I have complied with requirements of Rule 6 of the Supreme Judicial Court Uniforin 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-vAh them the <br /> advantages and dlsadvantages of the various:=n. <br /> Signature of Attorney of Record: X Date: 118118 <br />