Complaint (assumpsit-money owed); deClaration; exhibit(s); summons in the distriCt Court of the fifth CirCuit state of hawai`i Plaintiff(s) Form #5DC07 Reserved for Court Use Civil No. Defendant(s) Plaintiff(s)/Plaintiff(s)' Attorney (Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Facsimile Numbers) 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): I 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 Reprographics (06/10) CommonLook® 508 Certified American LegalNet, Inc. www.FormsWorkFlow.com COMPA 5D-P-173 SummonS In The DISTrIcT courT of The fIfTh cIrcuIT STaTe of hawaI`I Plaintiff(s) Form #5DC50 Reserved for Court Use Civil No. Defendant(s) Plaintiff(s)/Plaintiff(s)' Attorney (Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Facsimile Numbers) SUMMONS THE STATE OF HAWAI`I: TO: The Director of Public Safety of the State of Hawai`i, his/her deputy or any police officer or other person authorized by the laws of the State of Hawai`i: You are commanded to summon the Defendant(s) to appear before the District Judge of this Court in his/her Courtroom, to appear at the Court designated below. The Summons 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. TO THE DEFENDANT(S): You are required to appear before the District Judge of this Court, in his/her Courtroom, on the day and at the time designated below. If the Defendant(s) is a corporation, Hawai`i law requires it to be represented by an attorney licensed to practice in the State of Hawai`i. IF YOU OR YOUR ATTORNEY FAIl TO ATTEND THE COURT HEARINg AT THE TImE AND PlACE DESIgNATED, DEFAUlT AND DEFAUlT JUDgmENT mAY bE TAkEN AgAINST YOU FOR THE RElIEF DEmANDED IN THE COmPlAINT at 8:45 a.m. on the Third Monday following date of service, and should said Monday be a legal holiday then upon the next Monday. mailing address for the District Court Division is 3970 ka`ana Street, Suite 207, li hue, Hawai`i 96766 Date: SUmmONS Clerk of the above-entitled Court In accordance with the Americans with Disabilities Act, and other applicable State and Federal laws, if you require an accommodation for a disability when working with a court program, service, or activity please contact the District Court Administration Office at PHONE NO. 482-2347, FAX 482-2509, OR TTY 482-2533 at least (10) working days in before your proceeding, hearing, or appointment date. Reprographics (06/10) SUMMONS 5D-P-230 American LegalNet, Inc. www.FormsWorkFlow.com CommonLook® 508 Certified