THE COMMONWEALTH OF MASSACHUSETTS
Housing Court Department
_______________________Division ________________________Address ________________________________ __________________,SS:
No. / / /C / V / / / / / /
STATEMENT OF MATERIAL FACTS
(Please Print) ___________________________ Plaintiff(s)
Address: ___________________________ ___________________________ Tel: ___________________________
_________________________________ Defendant(s)
Address: ___________________________ ___________________________ Tel: ___________________________
BRIEFLY STATE THE FACTS:
Signed under the pains and penalties of perjury on: __________________________ Date: Signature: _____________________________________