COMPLAINT (PERSONAL INJURY/ PROPERTY DAMAGE); SUMMONS IN THE DISTRICT COURT OF THE FIFTH CIRCUIT STATE OF HAWAI`I Plaintiff Form 5DC09 Reserved for Court Use Civil No. Defendant Filing Party/Attorney Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Fax Number or Email Date of Injury/Damage: COMPLAINT 1. This Court has jurisdiction over this matter and venue is proper. 2. On or about the date of injury/damage stated above, defendant intentionally and/or negligently injured Plaintiff and/or damaged Plaintiff's property as follows: (state location of incident and briefly explain what happened) 3. As a result of the incident, Defendant caused the following damages: Physical Injury (Do not state the dollar amount, but give a brief description of the injury ): Property Damage in the amount of $ __________________________________ (Describe the type of damage): 4. Defendant has refused to pay for Plaintiff's damages. 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 US Military. The following Defendant is an active duty member of the US Military. Name:_____________________________. I am unable to determine whether the Defendant is an active duty member of the US Military. Please attach a separate sheet indicating what attempt was made to determine Defendant's military status. 6. Plaintiff asks for judgment against defendant for the damages proved. In addition, the court may award court costs, interest and reasonable attorney's fees as allowed by statute. Date: Signature of Filing Party/Attorney: Print/Type Name: 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 ten (10) working days before your proceeding, hearing, or appointment date. 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 5D-P-175 (Rev. 08/03/2011) CommonLook® 508 Certified Reprographics (09/11) 5D American LegalNet, Inc. www.FormsWorkFlow.com Form 5DC09