"Statement of Damages" - Massachusetts

Statement of Damages is a legal document that was released by the Trial Court of Massachusetts - a government authority operating within Massachusetts.

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  • Released on December 1, 2018;
  • The latest edition currently provided by the Trial Court of Massachusetts;
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DOCKET NO.
STATEMENT OF DAMAGES
Trial Court of Massachusetts
G.L. c. 218, § 19A(a)
PLAINTIFF(s)
DEFENDANT(s)
DATE FILED
INSTRUCTIONS: THIS FORM MUST BE COMPLETED AND
COURT DIVISION
FILED WITH THE COMPLAINT OR OTHER INITIAL
PLEADING IN ALL DISTRICT AND BOSTON MUNICIPAL COURT CIVIL
ACTIONS SEEKING MONEY DAMAGES.
TORT CLAIMS
AMOUNT
A.
Documented medical expenses to date:
$ ________
1. Total hospital expenses: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
2. Total doctor expenses: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
3. Total chiropractic expenses: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
4. Total physical therapy expenses: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Total other expenses (describe) _______________________________
$ ________
_________________________________________________________
$ ________
SUBTOTAL:
B.
Documented lost wages and compensation to date: . . . . . . . . . . . . . . . . . . .
$ ________
C.
Documented property damages to date: . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
D.
Reasonably anticipated future medical and hospital expenses: . . . . . . . . . .
$ ________
E.
Reasonable anticipated lost wages: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
F.
Other documented items of damage (describe): _____________________
$ ________
___________________________________________________________
G.
Brief description of Plaintiff's injury, including nature and extent of injury:
___________________________________________________________
___________________________________________________________
___________________________________________________________
TOTAL: $
For this form, disregard double or treble damage claims; indicate single damages only.
CONTRACT CLAIMS
AMOUNT
This action includes a claim involving collection of a debt incurred pursuant to a revolving
credit agreement. Mass. R. Civ. P. 8.1(a)
Provide a detailed description of the claim(s): ______________________
$ ________
___________________________________________________________
$ ________
___________________________________________________________
$ ________
TOTAL: $
For this form, disregard double or treble damage claims; indicate single damages only.
ATTORNEY FOR PLAINTIFF (OR UNREPRESENTED PLAINTIFF)
DEFENDANT'S NAME AND ADDRESS:
_________________________________________
_________________________________________
SIGNATURE
DATE
_________________________________________
_________________________________________
PRINT OR TYPE NAME
B.B.O. #
_________________________________________
_________________________________________
ADDRESS
_________________________________________
_________________________________________
CERTIFICATION PURSUANT TO SJC RULE 1:18: I hereby certify that I have complied with requirements of Rule 5 of the Supreme Judicial Court Uniform Rules
on Dispute Resolution (SJC Rule 1:18) requiring that I provide my clients with information about court-connected dispute resolution services and discuss with
them the advantages and disadvantages of the various methods of dispute resolution.
Signature of Attorney on Record:
Date:
12.18
DOCKET NO.
STATEMENT OF DAMAGES
Trial Court of Massachusetts
G.L. c. 218, § 19A(a)
PLAINTIFF(s)
DEFENDANT(s)
DATE FILED
INSTRUCTIONS: THIS FORM MUST BE COMPLETED AND
COURT DIVISION
FILED WITH THE COMPLAINT OR OTHER INITIAL
PLEADING IN ALL DISTRICT AND BOSTON MUNICIPAL COURT CIVIL
ACTIONS SEEKING MONEY DAMAGES.
TORT CLAIMS
AMOUNT
A.
Documented medical expenses to date:
$ ________
1. Total hospital expenses: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
2. Total doctor expenses: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
3. Total chiropractic expenses: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
4. Total physical therapy expenses: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Total other expenses (describe) _______________________________
$ ________
_________________________________________________________
$ ________
SUBTOTAL:
B.
Documented lost wages and compensation to date: . . . . . . . . . . . . . . . . . . .
$ ________
C.
Documented property damages to date: . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
D.
Reasonably anticipated future medical and hospital expenses: . . . . . . . . . .
$ ________
E.
Reasonable anticipated lost wages: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
$ ________
F.
Other documented items of damage (describe): _____________________
$ ________
___________________________________________________________
G.
Brief description of Plaintiff's injury, including nature and extent of injury:
___________________________________________________________
___________________________________________________________
___________________________________________________________
TOTAL: $
For this form, disregard double or treble damage claims; indicate single damages only.
CONTRACT CLAIMS
AMOUNT
This action includes a claim involving collection of a debt incurred pursuant to a revolving
credit agreement. Mass. R. Civ. P. 8.1(a)
Provide a detailed description of the claim(s): ______________________
$ ________
___________________________________________________________
$ ________
___________________________________________________________
$ ________
TOTAL: $
For this form, disregard double or treble damage claims; indicate single damages only.
ATTORNEY FOR PLAINTIFF (OR UNREPRESENTED PLAINTIFF)
DEFENDANT'S NAME AND ADDRESS:
_________________________________________
_________________________________________
SIGNATURE
DATE
_________________________________________
_________________________________________
PRINT OR TYPE NAME
B.B.O. #
_________________________________________
_________________________________________
ADDRESS
_________________________________________
_________________________________________
CERTIFICATION PURSUANT TO SJC RULE 1:18: I hereby certify that I have complied with requirements of Rule 5 of the Supreme Judicial Court Uniform Rules
on Dispute Resolution (SJC Rule 1:18) requiring that I provide my clients with information about court-connected dispute resolution services and discuss with
them the advantages and disadvantages of the various methods of dispute resolution.
Signature of Attorney on Record:
Date:
12.18