STATEMENT OF CLAIM AND NOTICE (GENERAL FORM) TWO-SIDED FORM IN THE SMALL CLAIMS DIVISION OF THE DISTRICT COURT OF THE THIRD CIRCUIT ______________________________ DIVISION STATE OF HAWAI‘I Form #3DC48B Plaintiff(s) Reserved for Court Use Defendant(s) 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/3SOCGF 3D-P-300 . 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 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 counter 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 fees 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 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-300 American LegalNet, Inc. www.FormsWorkflow.com