12.18 ATTORNEY FOR PLAINTIFF (OR UNREPRESENTED PLAINTIFF) STATEMENT OF DAMAGES G.L. c. 218, 247 19A(a) DOCKET NO. PLAINTIFF(s) DEFENDANT(s) DATE FILED INSTRUCTIONS: THIS FORM MUST BE COMPLETED AND FILED WITH THE COMPLAINT OR OTHER INITIAL PLEADING IN ALL DISTRICT AND BOSTON MUNICIPAL COURT CIVIL ACTIONS SEEKING MONEY DAMAGES. COURT DIVISION 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: $ $ $ $ $ For this form, disregard double or treble damage claims; indicate single damages only. TOTAL: $ CONTRACT CLAIMS AMOUNT Provide a detailed description of the claim(s): For this form, disregard double or treble damage claims; indicate single damages only. TOTAL: $ DEFENDANT'S NAME AND ADDRESS: SIGNATUREDATE PRINT OR TYPE NAMEB.B.O. # ADDRESS $ $ $ Trial Court of Massachusetts This action includes a claim involving collection of a debt incurred pursuant to a revolvingcredit agreement. Mass. R. Civ. P. 8.1(a) 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: American LegalNet, Inc. www.FormsWorkFlow.com