COMPLAINT (ASSUMPSIT-SUMMARY POSSESSION/ LANDLORD - TENANT, DAMAGES); DECLARATION; EXHIBIT(S); SUMMONS IN THE DISTRICT COURT OF THE SECOND CIRCUIT DIVISION STATE OF HAWAI`I Plaintiff(s) Form #2DC08 Reserved for Court Use Civil No. Defendant(s) Plaintiff(s)/Plaintiff(s)' Attorney (Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Facsimile Numbers) Premises Address: COMPLAINT l. This Court has jurisdiction over this matter and venue is proper. 2. Plaintiff(s) is the landlord or the agent for the landlord of the property. 3. The premises is located in this division of this Court. 4. Defendant(s) rents and/or is in possession of the property and/or is a personal guarantor under the rental agreement of the property. 5. There is a written rental agreement for the property. A copy of the written rental agreement for the premises (and any amendments to the rental agreement) is attached. There is no written rental agreement for the property, only an oral agreement. There is an expired written rental agreement for the property. A copy of the written rental agreement (and any amendments to the rental agreement) is attached. Defendant(s) is/are month-to-month tenant(s). 6. Defendant(s) has broken the rental agreement because: Unpaid rent $ Other 7. Written notice was given to Defendant(s) on (date) to correct this situation , 20 as follows: 5-day non-payment 10-day non-monetary default 45-day termination of month-to-month tenancy or as specified in the rental agreement or statute(s). A copy of the written notice is attached. 8. Despite the notice, Defendant(s) has failed to correct this situation and still is in possession of the premises. 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 Reprographics (05/11) Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com COMPASP 2D-P-221 COMPLAINT (continued) 9. The Servicemembers Civil Relief Act, 50 U.S.C. App. §501 may apply to a Defendant who is classified active duty as defined in the Act. Please check all that apply. To the best of my knowledge, the Defendant is not an active duty member of the Military. The following Defendant is an active duty member of the Military. Name: I am unable to determine whether the Defendant is an active duty member of the Military. Please attach separate sheet indicating what attempt was made to determine Defendant's military status. 10. As of (date): Defendant(s) owed Plaintiff(s) $ for: Rent itemized as follows: Other: Plaintiff is asking the Court for the following: A. A Judgment giving Plaintiff possession of the premises. B. A Writ of Possession directing the Sheriff or Police Officer to: 1. Remove Defendant from the premises and all persons possessing the premises through Defendant; 2. Remove from the premises all personal belongings of Defendant and of any other person; and 3. Put Plaintiff(s) in possession of the premises. C. Judgment against Defendant for $ . In addition, the Court may award additional rent and other charges owed under the rental agreement, damages, court costs, interest, and reasonable attorney's fees. Signature of Plaintiff(s)/Plaintiff(s) Attorney: Date: Print/Type Name(s): DECLARATION I DECLARE UNDER PENALTY OF PERJURY THAT WHAT IS STATED IN THE COMPLAINT IS TRUE AND CORRECT. Signature of Declarant: Date: Print/Type Name(s): In accordance with the Americans with Disabilities Act , and other applicable State and Federal laws, if you require an accommodation for your disability when working with a court program, service, or activity please contact the District Court Administration Office at PHONE NO. 244-2800, FAX 244-2849, OR TTY 244-2889 at least (10) working days before your preceeding, hearing, or appointment date. For Civil related matters, please call 244-2706 or visit the Service Center at 2145 Main Street, Room 141A, Wailuku, Hawai`i 96793. Reprographics (05/11) Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com COMPASP 2D-P-221