12.18
ATTORNEY FOR PLAINTIFF (OR UNREPRESENTED PLAINTIFF)
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STATEMENT OF DAMAGES
G.L. c. 218, § 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) _______________________________
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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): _____________________
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G. Brief description of Plaintiff's injury, including nature and extent of injury:
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$ ________
$ ________
$ ________
$ ________
$ ________
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): ______________________
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For this form, disregard double or treble damage claims; indicate single damages only. TOTAL:
$
DEFENDANT'S NAME AND ADDRESS:
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SIGNATURE DATE
PRINT OR TYPE NAME B.B.O. #
ADDRESS
$ ________
$ ________
$ ________
Trial Court of Massachusetts
This action includes a claim involving collection of a debt incurred pursuant to a revolving
credit 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:
