STATEMENT OF CLAIM AND NOTICE [DISAGREEMENT ABOUT SECURITY DEPOSIT-RESIDENTIAL] IN THE SMALL CLAIMS DIVISION OF THE DISTRICT COURT OF THE FIRST CIRCUIT _______________________ DIVISION Choose One STATE OF HAWAI`I Plaintiff Form #1DC05 Reserved for Court Use Civil No. Defendant Filing Party Name, Address, Telephone and Fax Number STATEMENT OF CLAIM Plaintiff alleges as follows: I am a resident of _________________________________________________________________________________. Since (date)___________________, 20___, Defendant owes me the sum of $_________________________for _____________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ Defendant resides and/or do business at _____________________________________________________________________________ ___________________________________________________________________________________________ in the State of Hawai`i. Plaintiff asks for judgment in the principal amount of $_____________________________________________________________. In addition, the Court may award court costs and interest. Where the Court determines that the landlord WRONGFULLY and WILLFULLY retained all or part of the security deposit, it MAY award the tenant damages equal to three times the security deposit retained, pursuant to Hawai`i Revised Statutes �521-44(h). DECLARATION I DECLARE UNDER PENALTY OF PERJURY THAT WHAT I HAVE STATED ABOVE IS TRUE AND CORRECT. Signature of Plaintiff: Date: Print/Type Name: I certify that this is a full, true, and correct copy of the original on file in this office. ________________________________________________ Clerk, District Court of the above Circuit, State of Hawai`i SEE PAGE 2 (Rev. 02/10/2010) 1D-P-1037 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Form#1DC05 Reprographics (03/10) 1DC NOTICE TO ___________________________________________________________________________________________________________: This Statement of Claim will be heard by a Judge at the address checked below on ____________________________, _________________________ 20 ___ at ________ ____ m. YOU MUST BE PRESENT ON THIS TRIAL DATE TO AVOID JUDGMENT BY DEFAULT. COURT ADDRESS G G G G G Honolulu Division `Ewa Division Ko`olaupoko OR Ko`olauloa Division Wahiaw OR Waialua Division Wai`anae Division 1111 Alakea Street, 10th Floor, Honolulu, Hawai`i 870 Fourth Street, Pearl City, Hawai`i 45-939 Po`okela Street, Kne'ohe, Hawai`i 1034 Kilani Avenue, Wahiaw, Hawai`i 4675 Kapolei Parkway, Kapolei, Hawai`i Mailing address for the above Court: 1111 Alakea Street, Civil Division, Third Floor, Honolulu, Hawai`i 96813 If you have witnesses, or documents related to this claim, you should bring them with you to the trial. If you wish to subpoena witnesses for trial, contact the clerk as soon as possible before trial. You may not be represented by an attorney in the Small Claims Division for security deposit cases. You have NO RIGHT TO APPEAL from a judgment of the Small Claims Division. IF YOU DO NOT APPEAR AND DEFEND ON THE DATE AND TIME STATED ABOVE, A DEFAULT JUDGMENT MAY BE ENTERED AGAINST YOU FOR THE AMOUNTS REQUESTED IN THIS STATEMENT OF CLAIM. Clerk This notice shall not be personally delivered between 10:00 p.m. and 6:00 a.m. on premises not open to the public, unless the court permits, in writing on this notice, personal delivery during those hours. In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require an accommodation for a disability when working with a court program, service, or activity, please contact the District Court Administration Office at PHONE NO. 538-5121, FAX 538-5233, or TTY 539-4853 at least ten (10) working days before your proceeding, hearing, or appointment date. For all Civil related matters, please call 538-5151 or visit the District Court Service Center at 1111 Alakea Street, Third (3rd) Floor. CommonLook� 508 Certified (Rev. 02/10/2010) 1D-P-1037 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Form#1DC05