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ll <br /> 11 <br /> DOCKET No.(s) Trial Court of Massachusetts �t <br /> CIVIL ACTION Superior C�o,}!r�SDepament <br /> ER SHEET County: <br /> COV "J(JJ P>:t <br /> DANT S 6'r `) <br /> FEN / <br /> DE ( ). O 1D t' �l <br /> INTIFF(S) 1" �i� c fWl v <br /> vvAaA Ab <br /> ATTORNEY (if known) <br /> ATTORNEY,FIRM NAME,ADDRESS AND TELEPHONES <br /> I l! <br /> 'Jf�IW A 1 <br /> A-A � <br /> 6(s � � ' E 3 i <br /> Board of Bar Overseers number. <br /> Origin code and track designation <br /> ❑ 4. F04 District Court Appeal c.231, S. 97 &104 (After <br /> Place an x in one box only: trial) (X) <br /> 0 1.F01 Original Complaint ❑ 5. F05 Reactivated after rescript; relief from <br /> 2.FO2 Removal to Sup.Ct. C.231,s.104 judgment/Order (Mass.R.Civ.P.60) (X) <br /> (Before trial) (F) El 6. E10 Summary Process Appeal (X) <br /> 3.F03 Retransfer to Sup.Ct. C.231,s.102C (X) <br /> TYPE OF ACTION AND TRACK DESIG S TIOIN AS ere erreCASs de) <br /> CODE NO. TYPE OF ACTION (specify) TRACK <br /> ( )Yes <br /> (>46 No <br /> ( ) F"Irmine <br /> Thef g is a full, itemized and detailed statement <br /> treble damage claimf the facts on s; ndicatefsingle damages only. <br /> money damages. For this form, disregard doub <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) . . . . . . . . . . . . . . . . . . . . . . • • 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 damages (describe) $ . . . . . . . . . . . . . <br /> G. Brief description of plaintiff's injury, including nature and extent of injury (describe) <br /> I <br /> $ . . . . . . . . . . . . . <br /> TOTAL $ . . . . . . . . . . . . . <br /> CONTRACT CLAIMS <br /> (Attach additional sheets as necessary) <br /> Provide a detailed description of claim(s): <br /> I <br /> i <br /> TOTAL $. . . . . . . . . . . . . <br /> PL UMBER, NAME AND COUNTY, ANY RELATED ACTION PENDING IN THE SUPERIOR <br /> EASE IDENTIFY, BY CASE N <br /> COURT DEPARTMENT <br /> "I hereby certify that I have complied with the.req cements ofRule S°� Court Uniform Rules on <br /> th inforrmation about Supreme lcourt-connected dispute <br /> Dispute Resolution (SJC Rule 1:18) requiring that I provide my cl ` <br /> resolution services and discuss with--tfiem the advantages an dis vantages of the various methods:' U ( i <br /> DATE: — <br /> Signature of Attorney of Record <br /> 40TC-6 mtc005-11/99 <br /> A.O.S.C.1-2000 <br />