Laserfiche WebLink
DOCKET NO.(S) <br /> CIVIL ACTION Trial Court of Massachusetts � <br /> i OVER SHEET _ °2 4 <br /> SuperiorCourt Department <br /> County: <br /> pIAINTIFF(S) <br /> DEFENDANT(S) <br /> .- -IfAl" �AZe�hdulC� <br /> SAd RA i. N A Y`!I G JJ-kJa, Wlt4�fur wG�s UwxTot M T43 k 02 Zoz)WG 6M2GQ <br /> ATfoRNEY,FIRM NAME,ADDRESS AND TELEPH NE ATTORNEY (if known) <br /> 4 <br /> LCo w.41 s tit C f gar Iz l 6o 1v'i� <br /> 33 6rC47 XjiEC% )20Aa ar. o Bak" r 7�� <br /> MASIn Sf v mA �Z�46good of B <br /> a <br /> r <br /> ®verseers number: <br /> rr. . <br /> F <br /> Origin code and track designation <br /> place an x in one box only: ❑ 4. F04 District Court Appeal c.231, s. 97 &104 (After <br /> 1.F01 Original Complaint trial) (X) <br /> 2.F02 Removal to Sup.Ct. C.231,s.104 ❑ 5. F05 Reactivated after rescript; relief from <br /> Before trial F <br /> ( ) O judgment/Order (Mass.R.Civ.P. 60) (X) <br /> r <br /> 3.FO3 Retransfer to Sup.Ct. C.231,s.102C (X) ❑ 6. E10 Summary Process Appeal (X) <br /> TYPE OF ACTION AND TRACK DESIGNATION (See reverse side) <br /> CODE NO. TYPE OF ACTION (specify) TRACK IS THIS A JURY CASE? 7 <br /> CCJL ZGd)11r�G A <br /> �PSAI— Yes No <br /> Thefollowing is a full, itemized and detailed statement of the facts on which plaintiff relies to determine <br /> money damages. For this form, disregard double or treble damage claims; indicate single damages only. <br /> TORT CLAIMS <br /> (Attach additional sheets as necessary) <br /> Documented medical expenses to date: I' <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) . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . $ . . . . . . . . . . . . . T <br /> Subtotal $ . . . . . . . . . . . . . <br /> Documented lost wages and compensation to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . <br /> I <br /> Documented property <br /> damages <br /> ReasoablYantpa ed futuemed al and hospital expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . . . <br /> i. <br /> Otherdocumenteditems of damages (describe) $ <br /> $ . . . . . . . . . . . . . <br /> Brief description of plaintiff's injury, including nature and extent of injury (describe) ' <br /> I I i u <br /> $ . . . . . . . . . . . . . <br /> TOTAL $. . . . . . . . . . . . . <br /> CONTRACT CLAIMS <br /> (Attach additional sheets as necessary) . <br /> rovide 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 /> Thereby certify that I have complied with the requirements of Rule 5 of the Supreme Judicial Court Uniform Rules on <br /> Dispute Resolution (SJC Rule 1:18) requiring that I p m provide clients with information about court-connected dispute <br /> y <br /> resolution services and discuss with them the advantages and disadvantages of the various methods:' <br /> Signature of Attorney of Record DATE: ;2 02- <br /> C-6 VC 05-11/99 <br /> O.S.C.1.2000 <br /> II <br />