CIVIL ACTION COVER SHEET 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 of Record: X RELATED ACTIONS: Please provide the case number, case name, and county of any related actions pending in the Superior Court. CONTRACT CLAIMS (attach additional sheets as necessary) 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 claim(s): TOTAL: $ TORT CLAIMS (attach additional sheets as necessary) 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 below) .......................................................................................................................................... $ Subtotal (A): $ B. Documented lost wages and compensation to date ...................................................................................................................................... $ C. Documented property damages to date ...................................................................................................................................................... $ D. Reasonably anticipated future medical and hospital expenses .................................................................................................................... $ E. Reasonably anticipated lost wages ............................................................................................................................................................... $ F. Other documented items of damages (describe below) ................................................................................................................................ $ G. Briefly describe plaintiff's injury, including the nature and extent of injury: TOTAL (A-F):$ STATEMENT OF DAMAGES PURSUANT TO G.L. c. 212, 247 3A The following is a full, itemized and detailed statement of the facts on which the undersigned plaintiff or plaintiff's counsel relies to determine money damages. For this form, disregard double or treble damage claims; indicate single damages only.TYPE OF ACTION AND TRACK DESIGNATION (see reverse side) CODE NO.TYPE OF ACTION (specify)TRACKHAS A JURY CLAIM BEEN MADE? COUNTYTrial Court of Massachusetts The Superior CourtSignature of Attorney/ Unrepresented Plaintiff: XDOCKET NUMBER YES NO Date: PLAINTIFF(S): ADDRESS: ATTORNEY: BBO: DEFENDANT(S): ADDRESS: ADDRESS:*If "Other" please describe: Date: YES NO YES NOIs there a claim under G.L. c. 93A?Is this a class action under Mass. R. Civ. P. 23? American LegalNet, Inc. www.FormsWorkFlow.com CIVIL ACTION COVER SHEET INSTRUCTIONS SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE TRANSFER YOUR SELECTION TO THE FACE SHEET EXAMPLE: CODE NO.TYPE OF ACTION (specify)TRACKHAS A JURY CLAIM BEEN MADE? B03Motor Vehicle Negligence-Personal Injury F . STATEMENT OF DAMAGES PURSUANT TO G.L. c. 212, 247 3A DUTY OF THE PLAINTIFF - The plaintiff shall set forth, on the face of the civil action cover sheet (or attach additional sheets as necessary), a statement specifying the facts on which the plaintiff relies to determine money damages. A copy of such civil action cover sheet, including the statement as to the damages, shall be served with the complaint. A clerk-magistrate shall not accept for filing a complaint, except as otherwise provided by law, unless it is accompanied by such a statement signed by the attorney or self-represented litigant. DUTY OF THE DEFENDANT - If the defendant believes that the statement of damages filed by the plaintiff is inadequate, the defendant may file with his/her answer a statement specifying the potential damages which may result if the plaintiff prevails. A CIVIL COVER SHEET MUST BE FILED WITH EACH COMPLAINT. FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY MAY RESULT IN DISMISSAL OF THIS ACTION. AC Actions Involving the State/Municipality * AA1 Contract Action involving Commonwealth, Municipality, MBTA, etc.(A) AB1 Tortious Action involving Commonwealth, Municipality, MBTA, etc.(A) AC1 Real Property Action involving Commonwealth, Municipality, MBTA etc.(A) AD1 Equity Action involving Commonwealth, Municipality, MBTA, etc.(A) AE1 Administrative Action involving Commonwealth, Municipality, MBTA,etc.(A) CN Contract/Business Cases A01 Services, Labor, and Materials(F) A02 Goods Sold and Delivered (F) A03 Commercial Paper(F) A04 Employment Contract(F) A05 Consumer Revolving Credit - M.R.C.P. 8.1(F) A06 Insurance Contract(F) A08 Sale or Lease of Real Estate(F) A12 Construction Dispute(A) A14 Interpleader(F) BA1 Governance, Conduct, Internal Affairs of Entities(A) BA3 Liability of Shareholders, Directors, Officers, Partners, etc.(A) BB1 Shareholder Derivative(A) BB2 Securities Transactions(A) BC1 Mergers, Consolidations, Sales of Assets, Issuance of Debt, Equity, etc.(A) BD1 Intellectual Property(A) BD2 Proprietary Information or Trade Secrets(A) BG1 Financial Institutions/Funds(A) BH1 Violation of Antitrust or Trade Regulation Laws(A) A99 Other Contract/Business Action - Specify(F) RP Real Property C01 Land Taking(F) C02 Zoning Appeal, G.L. c. 40A(F) C03 Dispute Concerning Title(F) C04 Foreclosure of a Mortgage(X) C05 Condominium Lien & Charges(X) C99 Other Real Property Action(F) MC Miscellaneous Civil Actions E18 Foreign Discovery Proceeding(X) E97 Prisoner Habeas Corpus(X) E22 Lottery Assignment, G.L. c. 10 24728(X) AB Abuse/Harassment Prevention E15 Abuse Prevention Petition, G.L. c. 209A(X)E21 Protection from Harassment, G.L. c. 258E(X) AA Administrative Civil Actions E02 Appeal from Administrative Agency, G.L. c. 30A(X) E03 Certiorari Action, G.L. c.249 2474(X) E05 Confirmation of Arbitration Awards(X) E06 Mass Antitrust Act, G. L. c. 93 2479(A) E07 Mass Antitrust Act, G. L. c. 93 2478(X) E08 Appointment of a Receiver(X) E09 Construction Surety Bond, G.L. c. 149 24724729, 29A(A) E10 Summary Process Appeal(X) E11 Worker's Compensation(X) E16 Auto Surcharge Appeal(X) E17 Civil Rights Act, G.L. c.12 24711H(A) E24 Appeal from District Court Commitment, G.L. c.123 2479(b)(X) E25 Pleural Registry (Asbestos cases) E95 Forfeiture, G.L. c.94C 24747(F) E99 Other Administrative Action(X) Z01 Medical Malpractice - Tribunal only, G.L. c. 231 24760B(F) Z02 Appeal Bond Denial(X) SO Sex Offender Review E12 SDP Commitment, G.L. c. 123A 24712(X)E14 SDP Petition, G.L. c. 123A 2479(b)(X) RC Restricted Civil Actions E19 Sex Offender Registry, G.L. c.6 247178M (X) E27 Minor Seeking Consent, G.L. c.112 24712S(X) ER Equitable Remedies D01 Specific Performance of a Contract(A) D02 Reach and Apply(F) D03 Injunction(F) D04 Reform/ Cancel Instrument(F) D05 Equitable Replevin(F) D06 Contribution or Indemnification(F) D07 Imposition of a Trust(A) D08 Minority Shareholder's Suit(A) D09 Interference in Contractual Relationship(F) D10 Accounting(A) D11 Enforcement of Restrictive Covenant(F) D12 Dissolution of a Partnership(F) D13 Declaratory Judgment, G.L. c.231A(A) D14 Dissolution of a Corporation(F) D99 Other Equity Action(F) PA Civil Actions Involving Incarcerated Party 206 PA1 Contrac