Ma Civil Cover Sheet Form – Fill Out and Use This PDF

TYPE OF ACTION AND TRACK DESIGNATION (See reverse side)

CODE NO.	TYPE OF ACTION (specify)	TRACK	IS THIS A JURY CASE?
			[ ] Yes [ ] No

The following is a full, itemized and detailed statement of the facts on which plaintiff relies to determine money damages. For this form, disregard double or treble damage claims; indicate single damages only.

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)	$_______________
	Subtotal	$_______________
B. Documented lost wages and compensation to date		$_______________
C. Documented property damages to date		$_______________
D. Reasonably anticipated future medical expenses		$_______________
E. Reasonably anticipated lost wages and compensation to date		$_______________

F.Other documented items of damages (describe)

$_______________

G. Brief description of plaintiff=s injury, including nature and extent of injury (describe)

Total $_______________

CONTRACT CLAIMS

(Attach additional sheets as necessary)

Provide a detailed description of claim(s):

TOTAL $...............

PLEASE IDENTIFY, BY CASE NUMBER, NAME AND COUNTY, ANY RELATED ACTION PENDING IN THE SUPERIOR COURT DEPARTMENT

ΑI hereby certify that I have complied with the 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.≅

Signature of Attorney of Record _________________________________________________	Date:
A.O.S.C. 3-2007

CIVIL ACTION COVER SHEET INSTRUCTIONS

SELECT CATEGORY THAT BEST DESCRIBES YOUR CASE

* CONTRACTS

* REAL PROPERTY

MISCELLANEOUS

*Claims against the Commonwealth or a municipality are type E03, Average Track, cases. **Claims filed by the Commonwealth pursuant to G L c 94C, s 47 Forfeiture cases are type

E95, Fast track.

TRANSFER YOUR SELECTION TO THE FACE SHEET.

EXAMPLE:

CODE NO.	TYPE OF ACTION (SPECIFY)	TRACK	IS THIS A JURY CASE?
B03	Motor Vehicle Negligence-Personal Injury	(F)	[ X ] Yes	[ ]

SUPERIOR COURT RULE 29

DUTY OF THE PLAINTIFF. The plaintiff or his/her counsel shall set forth, on the face sheet (or attach additional sheets as necessary), a statement specifying in full and itemized detail the facts upon which the plaintiff then relies as constituting money damages. A copy of such civil action cover sheet, including the statement as to the damages, shall be served on the defendant together with the complaint. If a statement of money

damages, where appropriate is not filed, the Clerk-Magistrate shall transfer the action as provided in Rule 29(5)(C).

DUTY OF THE DEFENDANT. Should the defendant believe the statement of damages filed by the plaintiff in any respect inadequate, he or his counsel may file with the answer a statement specifying in reasonable detail the potential damages which may result should the plaintiff

prevail. Such statement, if any, shall be served with the answer.

A CIVIL ACTION COVER SHEET MUST BE FILED WITH EACH COMPLAINT.

FAILURE TO COMPLETE THIS COVER SHEET THOROUGHLY AND ACCURATELY

MAY RESULT IN DISMISSAL OF THIS ACTION.