Free Statement of Damages - Massachusetts

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

Docket No.: Division:

Trial Court of Massachusetts District Court Department
Defendant(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): ____________________________ _______________________________________________________________ _______________________________________________________________ For this form, disregard double or treble damage claims; indicate single damages only. TOTAL CONTRACT CLAIMS: ATTORNEY FOR PLAINTIFF (OR PRO SE PLAINTIFF): Signature: ________________________________________ Type Name: ______________________________________ Address: ________________________________________ Phone: _________________________________________ B.B.O.#: _________________________________________ Date: ___________________________________________ AMOUNT $_______________ $_______________ $_______________

$_______________

DEFENDANT'S NAME AND ADDRESS & PHONE: ________________________________________ ________________________________________ ________________________________________

08/06