STATEMENT OF CLAIM AND NOTICE TWO-SIDED FORM [DISAGREEMENT ABOUT SECURITY DEPOSIT-RESIDENTIAL] Form #2DC48A IN THE SMALL CLAIMS DIVISION OF THE DISTRICT COURT OF THE SECOND CIRCUIT ______________________________ DIVISION STATE OF HAWAI‘I Plaintiff(s) Reserved for Court Use Defendant(s) Civil No. Filing Party(ies)' Name, Firm Name (if applicable), Address, Telephone and Facsimile Numbers Plaintiff(s) alleges as follows: he is/are a resident(s) of Since , 20 , the defendant(s) owes/owe plaintiff(s) the sum of $ for Defendant(s) reside(s) and/or does/do business at in the State of Hawai‘i. Plaintiff(s) ask 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 portion of the security deposit retained. c:\wp51\wpdoc\soc.2x Reprographics (9/06) I do hereby 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 REVERSE SIDE 2D-P-303 American LegalNet, Inc. www.FormsWorkflow.com AFFIDAVIT Affiant, being first duly sworn on oath says that the foregoing is a just and true statement of the amount owing by defendant(s) to plaintiff(s). day of Signature of Affiant: Subscribed and sworn to before me this , 20 , Print/Type Name of Affiant: Notary Public, State of My commission expires: Clerk of the above-entitled Court NOTICE TO: : Please take notice that this Statement of Claim will be heard by the District Judge of this Court, in his/her Courtroom, at the address checked below on , , 20 ,at .M., or as soon thereafter as parties may be heard. YOU ARE REQUIRED TO BE PRESENT ON THIS TRIAL DATE TO AVOID JUDGMENT BY DEFAULT. COURT ADDRESS G Wailuku Division 2145 Main Street, Courtroom 3D, Third Floor, Wailuku, Hawai‘i, 96793 G Lahaina Division 1870 HonoaPi‘ilani Highway, Lahaina, Hawai‘i, 96761 G Hana Division 4974 Uakea Road, Hana, Hawai‘i, 96713 G Molokai Division Kaunakakai, Molokai, Hawai‘i, 96748 G Lanai Division Lanai City, Lanai, Hawai‘i, 96763 Mailing address for the above Courts: 2145 Main Street, Room 106, Wailuku, Hawai‘i 96793 If you have witnesses, or documents bearing on this claim, you should bring them with you at the time of the hearing. If you wish to have witnesses subpoenaed, see the clerk at once for assistance. If you admit the claim, but desire additional time to pay, you must come to the trial in person and state the circumstances to the Court. You may not be represented by an attorney in the Small Claims Division for security deposit cases. You have no right to APPEAL from the judgment of the Small Claims Division. You may not elect to have security deposit case transferred to the Regular Claims Division of the District Court. YOUR FAILURE TO APPEAR AND DEFEND ON THE DATE AND TIME STATED ABOVE MAY RESULT IN A DEFAULT JUDGMENT AGAINST YOU FOR RELIEF DEMANDED IN THIS STATEMENT OF CLAIM. Clerk of the above-entitled Court 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 a judge of the above-entitled court permits, in writing on this summons, personal delivery during those hours. In accordance with the Americans with Disabilities Act, if you require an accommodation for your disability, please contact the District Court Administration Office at PHONE NO. 244-2800, FAX 244-2849, or TTY 244-2865 at least ten (10) working days in advance of your hearing or appointment date. 2D-P-303 (9/06) Clear form American LegalNet, Inc. www.FormsWorkflow.com