The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02

LIT Lab Home | About The Explorer | Find & Compare | Explore: Massachusetts Lists

Here is the text we could read:

STATEMENT OF DAMAGES 
G.L. c. 218, § 19A(a)

 DOCKET NO. 

 Trial Court of Massachusetts

 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)  _______________________________ 
     _________________________________________________________ 
  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): _____________________ 
 
___________________________________________________________ 
 G.   Brief description of Plaintiff's injury, including nature and extent of injury: 
 
 
 

___________________________________________________________ 
___________________________________________________________ 
___________________________________________________________

 
 
 
 
 

  
                    $ ________

         $ ________ 
         $ ________ 
         $ ________ 
         $ ________ 
         $ ________

For this form, disregard double or treble damage claims; indicate single damages only.                 TOTAL: $
CONTRACT CLAIMS

AMOUNT
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 the claim(s):  ______________________ 
___________________________________________________________ 
___________________________________________________________

                    $ ________ 
         $ ________ 
  
         $ ________
  

For this form, disregard double or treble damage claims; indicate single damages only.                 TOTAL: $
 ATTORNEY FOR PLAINTIFF (OR UNREPRESENTED PLAINTIFF) 

 DEFENDANT'S NAME AND ADDRESS: 

  _________________________________________ 
DATE
  SIGNATURE
 _________________________________________ 
B.B.O. #
  PRINT OR TYPE NAME
 _________________________________________ 
  ADDRESS
 _________________________________________ 
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: 
12.18

Date:

Statement of damages: G.L. c.218

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Massachusetts state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from www.mass.gov (2023-03)
Page(s): 1
Fields(s): 39
Average fields per page: 39
Reading Level: Grade 13
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

Here are the fields we could identify.

form_subform_text_field__1 was form1[0].#subform[0].TextField3[0] (0.58 conf)
form_subform_text_field__2 was form1[0].#subform[0].TextField3[1] (0.37 conf)
form_subform_text_field__3 was form1[0].#subform[0].TextField3[2] (0.37 conf)
form_subform_text_field__4 was form1[0].#subform[0].TextField3[3] (0.37 conf)
form_subform_text_field__5 was form1[0].#subform[0].TextField2[0] (0.37 conf)
form_subform_date_field was form1[0].#subform[0].DateField1[0] (0.39 conf)
form_subform_text_field__6 was form1[0].#subform[0].TextField2[1] (0.37 conf)
form_subform_text_field__7 was form1[0].#subform[0].TextField3[4] (0.37 conf)
form_subform_text_field__8 was form1[0].#subform[0].TextField3[5] (0.37 conf)
form_subform_text_field__9 was form1[0].#subform[0].TextField3[6] (0.37 conf)
form_subform_text_field__10 was form1[0].#subform[0].TextField3[7] (0.37 conf)
form_subform_text_field__11 was form1[0].#subform[0].TextField3[8] (0.37 conf)
form_subform_text_field__12 was form1[0].#subform[0].TextField3[9] (0.37 conf)
form_subform_text_field__13 was form1[0].#subform[0].TextField3[10] (0.37 conf)
form_subform_text_field__14 was form1[0].#subform[0].TextField3[11] (0.37 conf)
form_subform_text_field__15 was form1[0].#subform[0].TextField3[12] (0.37 conf)
form_subform_text_field__16 was form1[0].#subform[0].TextField3[13] (0.37 conf)
form_subform_text_field__17 was form1[0].#subform[0].TextField3[14] (0.37 conf)
form_subform_text_field__18 was form1[0].#subform[0].TextField3[15] (0.37 conf)
form_subform_text_field__19 was form1[0].#subform[0].TextField3[16] (0.37 conf)
form_subform_text_field__20 was form1[0].#subform[0].TextField3[17] (0.37 conf)
form_subform_text_field__21 was form1[0].#subform[0].TextField3[18] (0.37 conf)
form_subform_text_field__22 was form1[0].#subform[0].TextField3[19] (0.37 conf)
form_subform_text_field__23 was form1[0].#subform[0].TextField3[20] (0.37 conf)
form_subform_text_field__24 was form1[0].#subform[0].TextField3[21] (0.37 conf)
form_subform_text_field__25 was form1[0].#subform[0].TextField3[22] (0.37 conf)
form_subform_text_field__26 was form1[0].#subform[0].TextField3[23] (0.37 conf)
form_subform_text_field__27 was form1[0].#subform[0].TextField3[24] (0.37 conf)
form_subform_text_field__28 was form1[0].#subform[0].TextField3[25] (0.37 conf)
form_subform_text_field__29 was form1[0].#subform[0].TextField3[26] (0.37 conf)
form_subform_text_field__30 was form1[0].#subform[0].TextField3[27] (0.37 conf)
form_subform_text_field__31 was form1[0].#subform[0].TextField3[28] (0.37 conf)
form_subform_text_field__32 was form1[0].#subform[0].TextField3[29] (0.37 conf)
form_subform_text_field__33 was form1[0].#subform[0].TextField3[30] (0.37 conf)
form_subform_text_field__34 was form1[0].#subform[0].TextField3[31] (0.37 conf)
form_subform_text_field__35 was form1[0].#subform[0].TextField3[32] (0.37 conf)
form_subform_text_field__36 was form1[0].#subform[0].TextField2[2] (0.37 conf)
form_subform_check_box was form1[0].#subform[0].CheckBox1[0] (0.42 conf)
form_subform_drop_list was form1[0].#subform[0].DropDownList1[0] (0.36 conf)

Create an Interactive Version of this Form:

The Weaver creates a draft guided interview from a template form, like the one provided here. You can use the link below to open this form in the Weaver. To learn more, read "Weaving" your form into a draft interview.

Launch Form in Weaver

The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Statement of damages: G.L. c.218

About This Form:

Identified Data Fields:

Create an Interactive Version of this Form:

The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02