STATEMENT OF CLAIM AND NOTICE TWO-SIDED FORM [DISAGREEMENT ABOUT SECURITY DEPOSIT-RESIDENTIAL] Form #3DC48A IN THE SMALL CLAIMS DIVISION OF THE DISTRICT COURT OF THE THIRD CIRCUIT ______________________________ DIVISION STATE OF HAWAI‘I Plaintiff(s) Reserved for Court Use Defendant(s) 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\10/1/97v/3SOC-SD 3D-P-299 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 , , 20 at .M., or as soon thereafter address checked below on as parties may be heard. YOU ARE REQUIRED TO BE PRESENT ON THIS HEARING DATE TO AVOID JUDGMENT BY DEFAULT. COURT ADDRESS G North & South Hilo Division 75 Aupuni Street, Courtroom 3, Hilo, Hawai‘i 96720 G Puna Division 16-200 Pili Mua Street, Kea‘au, Hawai‘i 96749 G North & South Kona Division 79-1020 Haukapila Street, Kealakekua, Hawai‘i 96750 G Ka‘u Division 95-5669 Mamalahoa Highway, Na‘alehu, Hawai‘i 96772 G South Kohala Division 67-5187 Kamamalu Street, Kamuela, Hawai‘i 96743 G Hamakua Division 45-3362 Mamane Street, Honoka‘a, Hawai‘i 96727 G North Kohala Division 54-3900 Government Main Road, Kapa‘au, Hawai‘i 96755 Mailing address for the above Courts: G 75 Aupuni Street, Room 205, Hilo, Hawai‘i 96720 G 79-1020 Haukapila Street, Kealakekua, Hawai‘i 96750 G 67-5187 Kamamalu Street, Kamuela, Hawai‘i 96743 If you wish to contest the case, a trial may be set at this 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 hearing 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 ADA Coordinator at PHONE NO. 934-5788, FAX 935-1959, or TTY 961-7525 at least ten (10) working days in advance of your hearing or appointment date. 3D-P-299 American LegalNet, Inc. www.FormsWorkflow.com