FOR USE IN NORFOLK COUNTY PILOT PROGRAM FOR CIVIL MONEY DAMAGE ACTIONS DISTRICT COURT STANDING ORDER NO. 1-16 PLAINTIFF(s) DEFENDANT(s) STATEMENT OF DAMAGES DOCKET NO. Trial Court of Massachusetts District Court Department DATE FILED INSTRUCTIONS: THIS FORM MUST BE COMPLETED AND FILED WITH THE COMPLAINT OR OTHER INITIAL PLEADING IN ALL DISTRICT COURT CIVIL ACTIONS SEEKING MONEY DAMAGES. COURT DIVISION This case involves only alleged This case involves any other form of contract, tort or statutory money damage claim. consumer credit debt claims. 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. C. D. E. F. G. Documented lost wages and compensation to date: . . . . . . . . . . . . . . . . . . . Documented property damages to date: . . . . . . . . . . . . . . . . . . . . . . . . . . . . Reasonably anticipated future medical and hospital expenses: . . . . . . . . . . Reasonable anticipated lost wages: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Other documented items of damage (describe): _____________________ ___________________________________________________________ Brief description of Plaintiff's injury, including nature and extent of injury: ___________________________________________________________ ___________________________________________________________ ___________________________________________________________ TOTAL: $ AMOUNT $ ________ $ ________ $ ________ CONTRACT CLAIMS Provide a detailed description of the claim(s): ______________________ ___________________________________________________________ ___________________________________________________________ For this form, disregard double or treble damage claims; indicate single damages only. ATTORNEY FOR PLAINTIFF (OR PRO SE DEFENDANT) $ ________ $ ________ $ ________ $ ________ $ ________ For this form, disregard double or treble damage claims; indicate single damages only. TOTAL: $ DEFENDANT'S NAME AND ADDRESS: _________________________________________ SIGNATURE PRINT OR TYPE NAME ADDRESS DATE _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com _________________________________________ B.B.O. # _________________________________________ _________________________________________ _________________________________________ (Rev. 4/16)