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11/18/2003 11:48 508775 WYNN HYANNIS PAGE 04 <br /> CIVIL ACTION DOCKET <br /> No(s) 711'191 Court of Massachusetts <br /> Court D <br /> " COVER SHEET Superior apartment <br /> County: BARNSTAAI.F _ <br /> PLAINTIFF(6) DEFENOANT(S) JAMES E. REGAN II,_ LRSHALL BRF14 <br /> JOSEPH WEINSTEIN AND PATRICIA NEZN$!ma- � d� (�7VlSNIr z IA F3,IzE(vBF�tR <br /> in thea capacit as <br /> ATIORNEV,FIRM NAME.ADDRESS AND TELEPHONE - ATTORNEY fit kM ) Appaa 6 <br /> ROBERT F. MILLS, M. (508) 775-3665 <br /> WYNN & WYNN, P.C. <br /> Bo.MofBJOQ HYANNIS, MA 02601 <br /> Origin code and track designation <br /> Place,an x in one box only: ❑ 4. F04 District Court Appeal c.231,a.07 8104(After- <br /> 1. Fol Original Complaint trial) (X) <br /> 2. F02 Removal to Sup.Ct.0.231,s.104 ❑ 5. F05 Reactivated after rescripi;relief from <br /> (Before trial) (F) judgment/Order(Mass.R.Civ.P.60) (X) <br /> ❑ 3. F03 Retransfer to Sup•Ct.C.231,s.102C(X) ❑ 6. E10 Summery Process Appeal(X) <br /> TYPE OF ACTION AND TRACK DESIGNATION(See reveres side) <br /> CODE NO. TYPE OF ACTION (specify) TRACK IS THIS A-JURY CASE? <br /> CO2 ZCN= APPEAL 40A ( ) ( )Yes 1D{)No- <br /> e follow ng s s fu temised en eta led statement of the acts on whlch plaintiff re lee to determine <br /> money damages. For this form, disregard double or treble damage claims;-Indicate single damages onl , <br /> TORT CLAIMS <br /> A. (Attach additional-sheets-as necessary) <br /> 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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $. . . . . . . . . . . . . <br /> Subtotal $.. . .. . . . . . . . . <br /> S. Documented lost wages and compensation to date . . . . . . . . . . . . . . . $. . . . . . . . . . . . . <br /> C. Documented property damages to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $. . . . . . . . . I . . . <br /> Reasonatty anticipated future medical and hospital expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $. . . . . . . . . . . . . <br /> Reasonably anticipated lost wages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $. . . . . . . . . . . . . <br /> Other documented Items of damages(describe) <br /> $. . . . . . . . . . . . . <br /> G. Brief description of plaintiff's injury. Including nature and extent of injury (describe) <br /> $. . . . . . . . . . . . . <br /> TOTAL 5. . . . . . . .. . . . <br /> CONTRACT CLAIMS <br /> (Attach additional sheets as necessary) <br /> Provide a detailed description of claim(s): <br /> TOTAL $. . . . . . . .. . .. <br /> PLEASE IDENTIFY, BY CASE NUMBER, NAME AND COUNTY, ANY RELATED ACTION PENDING IN THE SUPERIOR <br /> COURT DEPARTMENT <br /> "I hereby certify that I have compiled with the requirements of Rule 8 of the Supreme Judicial Court Uniform Rules on <br /> Dispute Resolution(SJC Rule 1:18) _ng theft de my cltents.with Information about court-connected-dispute <br /> resolution services and discuss wkh a thea n gas and disadvantages of the various methods:' <br /> Signature of Attorney of Record DATE: 11/17/03 <br /> ROBERr E. M2= <br /> AOFC-em1c00S-11/99 <br /> A.O.S.C.1.2090 <br />