STATEMENT OF CLAIM AND NOTICE (GENERAL FORM) TWO-SIDED FORM IN THE SMALL CLAIMS DIVISION OF THE DISTRICT COURT OF THE SECOND CIRCUIT ______________________________ DIVISION STATE OF HAWAI‘I Form #2DC48B Plaintiff(s) Reserved for Court Use Defendant(s) Civil No. Filing Party(ies)/Filing Party(ies)' Attorney Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Plaintiff(s) alleges as follows: he is/are a resident and/or does/do business at Since , 20 ,the defendant(s) owes/owe the 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, interest. c:\wp51\wpdoc\soc.2x\10/1/97v 2D-P-302 Reprographics (8/06) . 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 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 Moloka‘i Division Kaunakakai, Moloka‘i, Hawai‘i, 96748 G Lana‘i Division Lana‘i 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 come with or without an attorney. You have no right to APPEAL if the case remains in the Small Claims Division. A Small Claims case cannot be transferred to the Regular Claims Division unless the plaintiff agrees to the transfer and payment of a fee to the clerk of the Court. If the claim is for MORE THAN $5,000.00, either party may have the case transferred to the Circuit Court for jury trial upon payment of $375.00 to the clerk of the Court. YOUR FAILURE TO APPEAR AND DEFEND ON THE DATE AND TIME STATED ABOVE MAY RESULT IN A DEFAULT JUDGMENT AGAINST YOU FOR THE 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-302 (8/06) American LegalNet, Inc. www.FormsWorkflow.com