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Statement Of Damages Form. This is a Massachusetts form and can be use in State District Court Statewide.
Tags: Statement Of Damages, Massachusetts Statewide, State District Court
STATEMENT OF
DAMAGES
G.L. c. 218, § 19A (a)
Docket No.:
Division:
Trial Court of Massachusetts
District Court Department
Defendant(s)
Plaintiff(s)
INSTRUCTIONS: THIS FORM MUST BE COMPLETED AND FILED WITH THE COMPLAINT OR OTHER INITIAL PLEADING IN ALL
DISTRICT 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): ____________________________
_______________________________________________________________
B. SUBTOTAL for lines 1-5 above:
C. Documented lost wages and compensation to date: ............................................
D. Documented property damages to date: ..................................................................
E. Reasonable anticipated future medical and hospital expenses: .......................
F. Reasonably anticipated lost wages: ..............................................................................
G. Other documented items of damage (Describe): ____________________
_______________________________________________________________
$_______________
$_______________
$_______________
$_______________
$_______________
$________________
$_______________
$_______________
$_______________
$_______________
$_______________
For this form, disregard double or treble damage claims, indicate single damages only.
TOTAL TORT CLAIMS for lines B-G above:
$______________
H. Brief description of Plaintiff's injury, including nature and extent of injury
(Describe): ______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
CONTRACT CLAIMS
Provide a detailed description of claim(s): ____________________________
_______________________________________________________________
AMOUNT
$_______________
$_______________
$_______________
_______________________________________________________________
For this form, disregard double or treble damage claims; indicate single
damages only.
TOTAL CONTRACT CLAIMS:
ATTORNEY FOR PLAINTIFF (OR PRO SE PLAINTIFF):
$_______________
DEFENDANT'S NAME AND ADDRESS & PHONE:
Signature: ________________________________________
________________________________________
Type Name: ______________________________________
________________________________________
Address: ________________________________________
________________________________________
Phone: _________________________________________
B.B.O.#: _________________________________________
Date: ___________________________________________
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