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DOCKET NO.(S) Trial Court of Massachusetts <br /> t CIVIL ACTION Superior Court Department <br /> COVER SHEET 0) \'��j�' County: <br /> '00-pIAINTIFF(S) DEFENDANTS) C dw••.�( M G o u a�t c- r�'fes' <br /> If fluCuvr-las } M4rlcn-c ��/CUV4��r Z,or��� i3p�rt e� P�pp*_alj 0L__A 11GnnGk <br /> i <br /> ATTORNEY,FIRM NAME,ADDRESS AND TELEPHONE ATTORNEY (if known) <br /> 1�olrrSra, llorcF-z. <br /> A. Mv.yly <br /> r ~, orkAAi(A_ cti.t <br /> Board of Bar overseers number: <br /> Origin code and track designation <br /> Place an x in one box only: PP�d� zap s ,� ❑ 4. F04 District Court Appeal c.231, s.97 &104 (After <br /> 1. F01 Original Complaint pip trial) (X) <br /> 2. F02 Removal to Sup.Ct. C.231,s.104 4L«str- ❑ 5. F05 Reactivated after rescript; relief from <br /> (Before trial) (F) judgment/Order (Mass.R.Civ.P. 60) (X) <br /> Q 3. F03 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? <br /> to-L )Yes -x ) No <br /> The following is a full, itemized and detailed statement of the facts on which plaintiff relies to determine <br /> noney damages. For this form, disregard double or treble damage claims; indicate single damages only. <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) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . <br /> Subtotal $. . . . . . . . . . <br /> B. Documented lost wages and compensation to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . <br /> C. Documented property damages to date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> D. Reasonably anticipated future medical and hospital expenses . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . $ . . . . . . . . . . . <br /> E. Reasonably anticipated lost wages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . $ . . . . . . . . . . . <br /> F. Other documented items of <br /> damages (describe) $ <br /> 9 <br /> Brief description of plaintiff's injury, including nature and extent of injury (describe) <br /> i <br /> i <br /> $ . . . . . . . . . . . <br /> TOTAL $ . . . . . . . . . . . . r <br /> CONTRACT CLAIMS f <br /> (Attach additional sheets as necessary) e A <br /> �� OLCtJtc 1 r R-1. 7_e,c1 GI <br /> Provide a detailed description of claim(s): o t�0 fl o ar R � ij <br /> dzficc-L , t%1u}.u, ►s clti• . . _ II <br /> Up� <br /> (� ,AA <br /> ol Ota HGGJ� nGMa..I BO�r� '6 �('PL�I <br /> t�.CGiSIc. QnnVllaf> C'.••.Ci���s <br /> TOTAL $. . . . . . . . . . . . <br /> PLEASE IDENTIFY, BY CASE NUMBER, NAME AND COUNTY, ANY.RELATED ACTION PENDING IN THE SUPERIOR j <br /> COURT DEPARTMENT ro/A <br /> "I hereby 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 provide my clients with information about court-connected dispute <br /> resolution services and discuss with them the advantages and disadvantages of the various methods." <br /> DATE: <br /> Signature of Attorney of Record 1 <br /> AOTC-6 mtc005-11/99 <br /> A.O.s.C.1-2000 <br />