Complaint (assumpsit-money owed); deClaration; exhibit(s); summons in the distriCt Court of the third CirCuit division state of hawai`i Plaintiff(s) Reserved for Court Use Form# 3DC07 Civil No. Defendant(s) Filing Party(ies)/Filing Party(ies)' Attorney (Name, Attorney No., Firm Name (if applicable), Address, Telephone and Fax No.) Amount Claimed by Plaintiff: Last Date of Indebtedness: COMPLAINT l. This Court has jurisdiction over this matter and venue is proper. 2. On or about , Defendant(s) owed money to Plaintiff(s) as follows: 3. A copy of the written instrument on which the debt is based is attached as Exhibit 1. 4. Plaintiff(s) asks for Judgment in the principal amount of $ . In addition, the Court may award court costs, interest and reasonable attorney's fees. 5. 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. Signature of Plaintiff(s)/Plaintiff(s) Attorney: Date: Print/Type Name(s): DECLARATION I have read this Complaint, know the contents and verify that the statements are true to my personal knowledge and belief. I DECLARE UNDER PENALTY OF PERJURY THAT THE ABOVE 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 ADA Coordinator at PHONE NO. (808) 961-7424, FAX (808) 961-7411, or TTY (808) 961-7422 at least (10) working days before your preceeding, hearing, or appointment date. For all Civil related matters, please call or visit the District Court at: Hilo Division, 777 Kilauea Avenue, Hilo, Ph. (808) 961-7515 · Kohala Division, 67-5187 Kamamalu Street, Kamuela, Ph. (808) 443-2030 · Kona Division, 79-1020 Haukapila Street, Kealakekua, Ph. (808) 322-8700. I certify that this is a full, true, and correct copy of the original on file in this office. CommonLook® 508 Certified Clerk, District Court of the above Circuit, State of Hawai`i COMPA 3D-P-260 Reprographics (09/09)