Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 1 of 21

EXHIBIT A
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 2 of 21

Commontwealth of flassachusetts
Lowell Bistrict Court
~ 4] Hurd Street:
a’ Lowell, MA 01852
; 901.232.3375

PATRICIA GHANLEY _, . ,
PLAINTIFF(S), crmNo. 191} CV Ad]

* RemnleTDN Loose f Ams SUMMONS
be LanfMon
TRS “Baetan ABI LELICA bic

DERENDANT(S)

THIS SUMMONS Is DIRECTED To REMING TAN LODE MS t WEP ITAL TY LLC

(Defendant's name)

1. This Notice is to inform you that you are being sued. The person or business suing
you is known as the Plaintiff. A copy of the Plaintiffs Complaint against you is attached and the
original has been filed in the Lowell Division of the District Court Department. You must
respond to this lawsuit in writing. If yon do not respond, the Plaintiff may obtain a court order
requiring you to pay money or provide other relief.

2. You must respond within 20 days to protect your rights. In order to protect your
right to defend yourself in this lawsuit, you must deliver or mail a written response called an
_ “Answer” to both the “Clerk’s Office for Civil Business, Lowell District Court, 4l Hurd Street,

. Lowéll, MA 01 852" and to the individual below: an oe oO ..

Bui SAN ss 'At Ag:

(name of Plaintiff or Plaintiff's attorney) oped J
Your Answer must be delivered or mailed within 20 days from the date the Summons was
delivered to you. If you need more time to respond, you may request an extension of time in
writing? from the Court.

. Your Answer must respond to each claim made by the Plaintiff, Your Answer is
your written response to the statements made by the Plaintiff in the Complaint. In your Answer
you must state whether you agree or disagree with each paragraph of the Complaint. You may

agree with some of the things the Plaintiff says and disagree with other things. You may also say
that you do not know whether one (or more) of the statements made in the Plaintiff's Complaint

is true. If you want to have your case heard by a jury, you must specifically request a jury trial
in your Answer, Even if you agree that you owe what is claimed, sending an Answer will
provide you with an opportunity to participate and explain your circumstances.

4, You must list any reason why you should not have to pay the Plaintiff what the
Plaintiff asks for, If you have any reason(s) why the Plaintiff should not get what the Plaintiff
asks for in the Complaint, you must write those reasons (or “defenses”) in your Answer.

proi Coney

—_ J Osputy Sheriff Sutfolk County

-2)-l4

 
 

 

Rey. 9/2015
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 3 of 21

5. You may lose this case if you do not send an Answer to the Court and the
Plaintiff. If you do not mail or deliver the Answer within 20 days, you may lose this case. You
will have no opportunity to tell your side of the story and the Court may order that the Plaintiff
receive everything requested in the Complaint. The Court may allow ‘a motion permitting the
Plaintiff take your property and/or wages. If you respond to the Complaint and appear at the
hearing, you will get an impartial hearing by a judge. Even if you choose to discuss this matter
with the Plaintiff (or the Plaintiff's lawyer), you should still send your Answer within 20 days.

' Bven.if you file an Answer, you can still reach an agreement with theiPlaintiff.

6, Legal Assistance. You may wish to get legal help from a lawyer. If you cannot get
legal help, you must still provide a written Answer to protect your rights or you may lose

the case. You may also obtain robertsdavid@example.org/courts/selfhelp.

7. You can also sue the Plaintiff. If you believe the Plaintiff owes you money or has
harmed you in some way related to the lawsuit, you must describe that in your Answer. If you
do not include these claims (called “Counterclaims”) in your written response, you may lose
your ability to sue the Plaintiff about anything related to this lawsuit.

8. You or your attorney must attend all court hearings. If you send your Answer to
the Court and the Plaintiff, you will protect your rights. The Court will send you a notice telling
you the date, time, and place of an impartial hearing before a judge. The judge will hear both
sides of any arguments and schedule any additional hearings. _

9, The civil number appearing on the front of this notice is the case docket number and
must appear on the front of your Answer. .

__ Witness Hon. Stacey J. Fortes, First Justice on

(SEAL)

 

 

Note: The number assigned to the Complaint by the Clark- eistrate atthe beginning
of the lawsuit should be indicated on the summons before it is served on the Defendant.

iB

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Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 4 of 21

EXHIBIT B
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 5 of 21

Conmmonivealth of Massachusetis

Lowell District Court
41 Hurd Street
Lowell, MA 01852

901.232.3375
PATRICIA { CHAN LEV |
PLAINTIFA(S), crNo. 17]/7 CU 841

 pemunldsron) voncinie 2° Has _ SUMMONS
Lit £ piaaianr Lic
DEFENDANT(S)

THIS SUMMONS IS DIRECTED TO ACNFIRD -rec Bac) Rn ePl(A Lie
Wefendant's name)

1. This Notice is to inform you that you are being sued, The person or business suing
you is known as the Plaintiff. A copy of the Plaintiffs Complaint against you is attached and the
original has been filed in the Lowell Division of the District Court Department. You must
respond to this lawsuit in writing. If you do not respond, the Plaintiff may obtain a court order
requiring you to pay money or provide other relief,

2. You must respond within 20 days to protect your rights. In order to protect your
right to defend yourself in this lawsuit, you must deliver or mail a written response called an
‘‘Answer” to both the “Clerk’s Office for Civil Business, Lowell District Court, 41 Hurd Street,
Lowell, MA 01852” and to the individual below:

  
 
 

. . voy, a
(name of Plaintiff or Plaintiff's attorney)

 

“EDI SDMMER..ST HA... (aadetess)

a Crain DMO

“Your Answer must be delivered or mailed within 20 days from the date the Summons was
delivered to you, If you need more time to respond, you may request an extension of time in
writing from the Court.

3. Your Answer must respond to each claim made by the Plaintiff. Your Answer is
your written response to the statements made by the Plaintiff in the Complaint. In your Answer
you must state whether you agree or disagree with each paragraph of the Complaint. You may
agree with some of the things the Plaintiff says and disagree with other thirigs. You may also say
that you do not know whether one (or more) of the statements made in the Plaintiff’s Complaint
is true, If you want to have your case heard by a jury, you must specifically request a jury trial
in your Answer. Even if you agree that you owe what is claimed, sending an Answer will
provide you with an opportunity to participate and explain your circumstances.

4, You must list any reason why you should not have to pay the Plaintiff what the
Plaintiff asks for, If you have any reason(s) why the Plaintiff should not get what the Plainuff
asks for in the Complaint, you must write those reasons (or “defenses’”’) in your Answer,

A true copy Attest: d
[ - Deputy Sherltf Suffolk County

6. 2)- 19

Rey. 9/2015

4
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 6 of 21

5. You may lose this case if you do not send am Answer to the Court and the
Plaintiff. If you do not mail or deliver the Answer within 20 days, you may lose this case. You
will have no opportunity to tell your side of the story and the Court may order that the Plaintiff
receive everything requested in the Complaint. The Court may allow b motion permitting the
Plaintiff take your property and/or wages. If you respond to the Complaint and appear at the
hearing, you will get an impartial hearing by a judge. Even if you choose to discuss this matter
with the Plaintiff (or the Plaintiff’s lawyer), you should still send your Answer within 20 days.

_ Even if you file an Answer, you can still reach an agreement with the Plaintiff.

6. Legal Assistance. You may wish to get legal help from a lawyer. If you cannot get
legal help, you must still provide a written Answer to protect your rights or you may lose
the case. You may also obtain robertsdavid@example.org/courts/selfhelp.

|
7. You can also sue the Plaintiff. If you believe the Plaintiff owes you money or has
harmed you in some way related to the lawsuit, you must describe that in your Answer. If you
do not include these claims (called ‘“Counterclaims’’) in your written response, you may lose
your ability to sue the Plaintiff about anything related to this lawsuit.

8. You or your attorney must attend all court hearings. If you send your Answer to
the Court and the Plaintiff, you will protect your rights. The Court will send you a notice telling
you the date, time, and place of an impartial hearing before ajudge. The judge will hear both
sides of any arguments and schedule any additional hearings. |

9. The civil number appearing on the front of this notice is the case docket number and
must appear on the front of your Answer.

   

 

\00 Rae AR

i

 

Note: The number assigned to the Complaintiby the Clerk-Migistrate-at ihe begioning
of the lawsuit should be indicated on the summons before it is served on the Defendant.

Te ,
Ee

Ree
ons

 

 

 

 

Rev. 9/2015 :
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 7 of 21

EXHIBIT C
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 8 of 21

COMMONWEALTH OF MASSACHUSETTS
DISTRICT COURT DEPARTMENT
OF THE TRIAL COURT
LOWELL DIVISION

MIDDLESEX, SS. CIVIL ACTION NO.

PATRICIA SHANLEY,
Plaintiff

V.
REMINGTON LODGING &
HOSPITALITY, LLC AND
ASHFORD TRS BOSTON
BILLERICA, LLC
Defendants
COMPLAINT AND JURY CLAIM

1. The plaintiff is Patricia Shanley, 135 Bridle Road, Billerica (Middlesex County)
Massachusetts.

2. The defendant is Remington Lodging & Hospitality, LLC with a principal
office/place of business at 14185 Dallas Parkway, Suite 1150, Dallas, TX 75254 whose resident
agent is Corporation Service Company, 84 State Street, Boston, MA 02109.

3, The defendant is Ashford TRS Boston Billerica, LLC with a principal place of
business at 14185 Dallas Parkway, Suite 1100, Dallas, TX 75254 whose resident agent is
Corporation Service Company, 84 State Street, Boston, MA 02109.

4. The defendant Remington Lodging & Hospitality, LLC does business in the

Commonwealth of Massachusetts, which included operating a Marriott Courtyard hotel at 270

Concord Road, Billerica (Middlesex County) Massachusetts.
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 9 of 21

é

5. The defendant Ashford TRS Boston Billerica, LLC does business in the
Commonwealth of Massachusetts, which includes operating a Marriott Courtyard hotel at 270
Concord Road, Billerica (Middlesex County) Massachusetts.

6. The defendants are subject to the jurisdiction of the courts of the Commonwealth
of Massachusetts by operation of but not limited to M.G.L. c. 223A, § 3.

7. The plaintiff was employed by the defendants at the Marriott Courtyard in
Billerica, Massachusetts since 1998. She served in various capacities as bartender, banquet
server and waitress.

8. On or about 2016, the defendants purchased, operated, and managed the Marriott
in Billerica and were the plaintiff's employers.

9. The plaintiffs compensation from the defendants always included tip income
along with an hourly wage.

10. Tip income made up a substantial portion of the plaintiff's compensation.

11. The defendants provided a complimentary breakfast/breakfast buffet for groups,
including tour groups staying or visiting the hotel.

12. _ Each patron partaking of the breakfast/buffet received a ticket which stated

“breakfast is inclusive with tax and gratuity.”

13. The plaintiff and other waitresses who served the breakfast/breakfast buffet
received $1.50 for tip income per individual or “per ticket” which was the “gratuity” to be paid
to the plaintiff and others.

14. _ Initially the tips were included in the payroll system but later the tickets were

collected and counted and the tips to the wait staff were determined and paid separately to the

staff.
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 10 of 21

15. In March 2017, the defendants’ manager (Ron Como) announced to the plaintiff
and others that the company will no longer pay tip income to the wait staff for the
breakfast/breakfast buffet “tickets,” although defendants’ continued to collect the gratuity/tip.

16. The plaintiff filed a complaint with the Massachusetts Attorney General’s Office
in May of 2017 and the Attorney General’s Office conducted an investigation.

17. In September of 2017, it was announced by the defendants that they would
resume paying the tip income to the wait staff.

18. The plaintiff earned and was entitled to the tips which were unlawfully withheld
and she was forced to work without the compensation from the tips for those seven months,
totaling $8,000.00.

19. As aresult of the plaintiff's complaining to the Attorney General’s Office, the
defendants retaliated against the plaintiff. In September of 2017 her hours were reduced
significantly and then she was removed from the work schedule entirely. The defendants
effectively terminated the plaintiff.

20. After the complaint was filed with the Attorney General, the defendants destroyed
all of the collected breakfast tickets.

21. On January 10, 2019, the plaintiff received authorization from the Attorney

General’s Office to pursue a private civil action.

COUNT I
VIOLATION OF THE FAIR LABOR STANDARDS ACT
29 U.S.C. § 216(b) AND 29 U.S.C. § 203(m)(2)(B)
BY REMINGTON LODGING & HOSPITALITY, LLC

22. The plaintiff restates and incorporates all of the allegations contained in

Paragraphs 1-21 as if specifically stated herein.
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 11 of 21

23. The plaintiff is entitled to bring a private action under the Fair Labor Standards
Act, 29 U.S.C. § 216(b) (“FLSA”) as a result of the defendants’ intentional and willful failure to
pay wages/ tips.

24.  29U.8.C. § 203(m)(2)(B) states that: “an employer may not keep tips received
by its employees for any purposes .. .An employer who violates this section shall be liable to the
employee effected in the amount of the sum of any tip credit and the additional equal amount is
liquidated damages.”

25. The defendant has repeatedly violated the FLSA by failing to pay tip
compensation.

26. The defendant is liable to the plaintiff in an amount equal to the plaintiff's unpaid
wages/tips and an additional equal amount as liquidated damages and attorney’s fees.

27. The defendant is also liable for such legal or equitable relief as may be
appropriate.

28. The award of attorney’s fees and costs is mandatory.

29. The defendant has no good faith or reasonable grounds for believing that it was
justified in failing to pay tip income.

WHEREFORE, the plaintiff demands the following relief against Remington Lodging &
Hospitality, LLC.;

a. Judgment for damages in the amount of $8,000.00 and a declaration that
the acts complained of herein are in violation of the FLSA and that the
defendant is liable to the plaintiff under the FLSA for any and all unpaid
tip wages;

b. Judgment for damages in the amount of $8,000.00 liquidated damages;
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 12 of 21

c An award of reasonable attorney’s fees and costs for the prosecution of
this suit; and
d. Such other further relief as this Court deems just and appropriate.
COUNT II
VIOLATION OF THE FAIR LABOR STANDARDS ACT
29 U.S.C. § 216(b)

BY ASHFORD TRS BOSTON BILLERICA, LLC

30. The plaintiff restates and incorporates all of the allegations contained in
Paragraphs 1- 29 as if specifically stated herein.

31. The plaintiff is entitled to bring a private action under the Fair Labor Standards
Act, 29 U.S.C. § 216(b) (“FLSA”) as a result of the defendants’ intentional and willful failure to
pay wages.

32.  29U.S.C. § 203(m)(2)(B) states that: “an employer may not keep tips received
by its employees for any purposes . ..An employer who violates this section shall be liable to the
employee effected in the amount of the sum of any tip credit and the additional equal amount is
liquidated damages.”

33. The defendant has repeatedly violated the FLSA by failing to pay tip
compensation.

34. The defendant is liable to the plaintiff in an amount equal to the plaintiff's unpaid
wages/tips and an additional equal amount as liquidated damages and attorney’s fees.

35. The defendant is also liable for such legal or equitable relief as may be
appropriate.

36. The award of attorney’s fees and costs is mandatory.

37. | The defendant has no good faith or reasonable grounds for believing that it was

justified in failing to pay tip income.
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 13 of 21

WHEREFORE, the plaintiff demands the following relief against Ashford TRS Boston
Billerica, LLC;
a. Judgment for damages in the amount of $8,000.00 and a declaration that
the acts complained of herein are in violation of the FLSA and that the

defendant is liable to the plaintiff under the FLSA for any and all unpaid

tip wages;
b. Judgment for damages in the amount of $8,000.00 liquidated damages;
c. An award of reasonable attorney’s fees and costs for the prosecution of

this suit; and
d. Such other further relief as this Court deems just and appropriate.
COUNT Il
VIOLATION OF M.G.L. c. 149, § 152A(b)

FOR FAILURE TO PAY WAGES AND TIPS AGAINST
REMINGTON LODGING & HOSPITALITY, LLC

38. The plaintiff restates and incorporates all of the allegations contained in
Paragraphs 1-37 as if specifically stated herein.

39. M.G.L. c. 149, § 152A(b) states that: “No employer or other persons shall
demand, request or accept from any wait staff employee . . . any payment or deduction from a tip
or service charge given to such wait staff employee . . ..No such employer or other person shall
retain or distribute in a manner inconsistent with this section any tip or service charge given
directly to the employee or person.”

40. “If an employer or person submits a bill, invoice or charge to a patron or other

person that imposes a service charge or tip, total proceeds of that service charge or tip shall be
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 14 of 21

remitted only to the wait staff employees in proportion to the service provided by those
employees,”

41. M.G.L.c. 149, § 152A(e) states that: “Any service charge or tip remitted by a
patron or person to employer shall be paid to the wait staff employee. . . .by the end of the same
business day and in no case later than the time set forth for timely payment of wages under §
148.

42. The defendant’s refusal to pay the earned wages/tips to the plaintiff violates the
law as stated above.

43. The defendant’s refusal to pay the tips and withdrawal of the tip income was
willful and the plaintiff has satisfied all of her prerequisites to sue pursuant to c. 149, § 148 and §
150. |

44. As aresult of the defendant’s actions, the defendant is subject to all of the civil
penalties and remedies set forth in M.G.L. c. 149, § 27C and is required by law by the statute to
make restitution for any tips accepted, distributed or retained in violation of this section with
interest thereof at the rate of 12% per annum.

45. The tip income to the plaintiff is considered wages. The defendant’s refusal to
pay wages for hours worked is in violation of M.G.L. c. 149, § 148.

46. Asaresult, the defendant is required to pay the amount withheld including
liquidated damages, treble damages, costs and attorney’s fees pursuant to M.G.L. c. 149, § 150

and c. 151, § 1B.
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 15 of 21

WHEREFORE, the plaintiff demands the following relief against Remington Lodging &
Hospitality, LLC.;

a. Judgment for damages in the amount of $8,000.00 and a declaration that
the acts complained of herein are in violation of the law and that the
defendant is liable to the plaintiff for any and all unpaid tip wages;

b. Judgment for damages in the amount of treble damages;

c. An award of reasonable attorney’s fees, interest and costs for the

prosecution of this suit; and

d, Such other further relief as this Court deems just and appropriate.

COUNT IV
VIOLATION OF M.G.L. c. 149, § 152A(b)
FOR FAILURE TO PAY WAGES AND TIPS AGAINST
ASHFORD TRS BOSTON BILLERICA, LLC

47, The plaintiff restates and incorporates all of the allegations contained in
Paragraphs 1-46 as if specifically stated herein.

48. M.G.L. c. 149, § 152A(b) states that: “No employer or other persons shall
demand, request or accept from any wait staff employee . . . any payment or deduction from a tip
or service charge given to such wait staff employee... .No such employer or other person shall
retain or distribute in a manner inconsistent with this section any tip or service charge given
directly to the employee or person.”

49. “If an employer or person submits a bill, invoice or charge to a patron or other
person that imposes a service charge or tip total proceeds of that service charge or tip shall be

remitted only to the wait staff employees in proportion to the service provided by those

employees.”
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 16 of 21

50. M.G.L.c. 149, § 152A(e) states that: “Any service charge or tip remitted by a
patron or person to employer shall be paid to the wait staff employee. . . .by the end of the same
business day and in no case later than the time set forth for timely payment of wages under §
148.

51. | The defendant’s refusal to pay the earned wages/tips to the plaintiff violates
Massachusetts General Laws as stated above.

52. The defendant’s refusal to pay the tips and withdrawal of the tip income was
willful and the plaintiff has satisfied all of her prerequisites to sue pursuant to c. 149, § 148 and §
150. |

53.  Asaresult of the defendant’s actions, the defendant is subject to all of the civil
penalties and remedies set forth in M.G.L. c. 149, § 27C and is required by law by the statute to
make restitution for any tips accepted, distributed or retained in violation of this section with
interest thereof at the rate of 12% per annum.

54, The tip income to the plaintiff is considered wages. The defendant’s refusal to
pay wages for hours worked is in violation of M.G.L. c. 149, § 148.

55.  Asaresult, the defendant is required to pay the amount withheld including
liquidated damages, treble damages, costs and attorney’s fees pursuant to M.G.L. c. 149, § 150

and c. 151, § IB.
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 17 of 21

WHEREFORE, the plaintiff demands the following relief against Ashford TRS Boston
Billerica, LLC;

a. Judgment for damages in the amount of $8,000.00 and a declaration that
the acts complained of herein are in violation of the law and that the
defendant is liable to the plaintiff for any and all unpaid tip wages;

b. Judgment for damages in the amount of treble damages;

C. An award of reasonable attorney’s fees, interest and costs for the

prosecution of this suit; and

d. Such other further relief as this Court deems just and appropriate.

COUNT V
RETALIATION AGAINST
REMINGTON LODGING & HOSPITALITY, LLC

56. The plaintiff restates and incorporates all of the allegations contained in
Paragraphs 1-55 as if specifically stated herein.

57. The defendant’s removal of the plaintiff from the work schedule after her
complaint to the Attorney General’s Office for non-payment of wages along with destroying
evidence is a willful retaliation and violates M.G.L. c. 151, § 19 which prohibits retaliation.

58. As aresult, pursuant to M.G.L. c. 151, § 19 the plaintiff is entitled to mandatory

compensatory damages, injunctive relief, mandatory triple damages, cost of litigation and

reasonable attorney’s fees.

WHEREFORE, the plaintiff demands judgment against Remington Lodging &

Hospitality, LLC as follows:

10
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 18 of 21

a. A declaration that the defendant violated both Mass. Law and the FLSA by
retaliation against the plaintiff, an order for compensatory damages in the amount of $8,000.00,
mandatory treble damages, reasonable attorney’s fees, interest and costs;

b. For the retaliation in violation of Massachusetts laws, an amount of mandatory

treble damages, costs and reasonable attorney’s fees.
COUNT VI
RETALIATION AGAINST
ASHFORD TRS BOSTON BILLERICA, LLC

59. _ The plaintiff restates and incorporates all of the allegations contained in
Paragraphs 1-58 as if specifically stated herein.

60. The defendant’s removal of the plaintiff from the work schedule after her
complaint to the Attorney General’s Office for non-payment of wages along with destroying
evidence is a willful retaliation and violates M.G.L. c. 151, § 19 which prohibits retaliation.

61. Asaresult, pursuant to M.G.L. c. 151, § 19 the plaintiff is entitled to mandatory
compensatory damages, injunctive relief, mandatory triple damages, cost of litigation and
reasonable attorney’s fees.

WHEREFORE, the plaintiff demands judgment against Ashford TRS Boston Billerica,

LLC as follows:

a. A declaration that the defendant violated both Mass. Law and the FLSA
by retaliation against the plaintiff, an order for compensatory damages in the
amount of $8,000.00, mandatory treble damages, reasonable attorney’s fees,
interest and costs;

b. For the retaliation in violation of Massachusetts laws, an amount of

mandatory treble damages, costs and reasonable attorney’s fees.

11
Case 1:19-cv-11519-DJC Document 1-1. Filed 07/11/19 Page 19 of 21

Dated: May 31, 2019

DEMAND FOR JURY TRIAL

The plaintiff demands a jury trial.

12

Respectfully submitted,

PLAINTIFF,
PATRICIA SHANLEY,

By her attorneys:

 

Bradford N.Louison (BBO#305755)
robertsdavid@example.org

Louison, Costello, Condon & Pfaff, LLP
101 Summer Street

Boston, MA 02110

901.232.3375

FAX: 901.232.3375
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 20 of 21

EXHIBIT D
Case 1:19-cv-11519-DJC Document 1-1 Filed 07/11/19 Page 21 of 21

 

 

 

 

 

Docket No.: . =
TAGES. . Trial Court of Massachusetts WwW
G.L.c.218,§19A(a) OY" AWE LL | District Court Department
Plaintiff(s) . _.. a . Defendant(s) REmid@ TAN) Lda GING +HOSbIrALITV
Pat ble A SHANL EY akwenen TRse Oncwnl AuLERicA Wc. |

 

 

INSTRUCTIONS: THIS FORM MUST BE COMPLETED AND FILED WITH THE COMPLAINT OR OTHER INITIAL PLEADING IN ALL
DISTRICT COURT CIVIL ACTIONS SEEKING MONEY DAMAGES.

; Rosca oe te ; EE ORR
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 Mater ......scccessssrssvssesssserseesssssaneesy
D. Documented property damages to date:
E. Reasonable anticipated future medical and hospital expenses: .......ssseseeeen
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):

 

 

 

 

 

 

 

For this form, disregard double or treble damage claims; indicate single
damages only.

 

TOTAL CONTRACT CLAIMS:

ATTORNEY F IFF.LOR PRO SE PLAINTIEF): DEFENDANT'S NAME AND ADDRESS & PHONE:
Signature: Yacht ern

Type Name: ORADHAOD Ne LOvIi<dM
Address: ld) gpomimEw o-r ap) Bostan MA
Phone:__Z/'7 437 O30rc

B.B.0#: 20.5 75.5

 

 

 

Date: s/asli§

 

 

 

 

 

]

08/06

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