COURT STATEMENT OF CLAIM AND NOTICE COUNTY OF TWO-SIDED FORM . . . . . . . . . SECURITY . EPOSIT-R. . . . . . . . . [DISAGREEMENT.ABOUT . . . . . . . . D. . . . . . . ESIDENTIAL]. . . . . . . . . . . . . . . . . . . Calendar No. : -against- Index No. : IN THE SMALL CLAIMS DIVISION OF THE DISTRICT COURT OF THE FIFTH CIRCUIT ______________________________ DIVISION STATE OF HAWAI‘I Plaintiff(s) Plaintiff(s) Form #5DC48A : JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... Reserved for Court Use Defendant(s) THE PEOPLE OF THE STATE OF NEW YORK Civil No. TO Filing Party(ies)' Name, Firm Name (if applicable), Address, Telephone and Facsimile Numbers GREETINGS: WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the Court Plaintiff(s) alleges as follows: located at County of he is/are room in a resident(s) of , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the Since , 20 , the defendant(s) owes/owe plaintiff(s) the sum of $ for Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. Witness, Honorable Court in County, , one of the Justices of the day of , 20 (Attorney must sign above and type name below) Defendant(s) reside(s) and/or does/do business at Attorney(s) for 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. Office and P.O. Address c:\wp51\wpdoc\soc.2x\10/1/97v 5D-E-248 (04/03) I do hereby certify that this is a full, true, and correct copy of the original on file in this office. Telephone No.: Facsimile No.: Clerk, District Court of the above Circuit, State of Hawai‘i E-Mail Address: Mobile Tel. No.: See REVERSE SIDE American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. : AFFIDAVIT : Index No. Calendar No. 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 JUDICIAL SUBPOENA Plaintiff(s)Signature of Affiant: Subscribed and sworn to before me this -against- , 20 : Print/Type :Name of Affiant: Notary Public, State of : My commission expires: Clerk of the above-entitled Court Defendant(s) : ...................................................... NOTICE TO: : THE PEOPLE OF THE STATE Claim will be heard Please take notice that this Statement ofOF NEW YORK by the District Judge of this Court, in his/her Courtroom, at the TO address checked below on , , 20 at .M., or as soon thereafter as parties may be heard. YOU ARE REQUIRED TO BE PRESENT ON THIS TRIAL DATE TO AVOID JUDGMENT BY DEFAULT. COURT ADDRESS G Lihue Division 3461 Weliweli Road, Koloa, Hawai‘i GREETINGS: G Kawaihau Division 3461 Weliweli Road, Koloa, Hawai‘i G Koloa Division WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before 3461 Weliweli Road, Koloa, Hawai‘i G Waimea Division 3461 Weliweli Road, Koloa, Hawai‘i , the Honorable at the Court G Hanalei Division 5-5358 Kuhio Highway, Hanalei, Hawai‘i located at County of in room , on the day of , Lihue, , at o'clock noon, and at any recessed Mailing address for the above Courts: 4357 Rice Street, Suite 101, 20 Hawai‘i 96766-1367in the or adjourned date, to testify and give evidence as a witness in this action on the part of the If you have witnesses, or documents bearing on this claim, you should bring them with you at the time of the hearing. If you wish to have witnesses subpoenaed, see the clerk at once for assistance. Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to If you admitparty on whose behalf this subpoena was issued for a to the trial in person and$50 and circumstances sustained as a the the claim, but desire additional time to pay, you must come maximum penalty of state the all damages to the Court. result of your failure to comply. You may not be represented by an attorney in the Small Claims Division for security deposit cases. Witness, Honorable Court in County, You have no right to APPEAL from the judgment of the Small Claims Division. day of , one of the Justices of the , 20 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. (Attorney must sign above and type name below) Attorney(s) for 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. Office and P.O. Address In accordance with the Americans with Disabilities Act, if you require an accommodation for your disability, please contact the District Court Administration Office at PHONE NO. 246-3347, FAX 246-3353, or TTY 539-4853 at least ten (10) working days in advance of your hearing or appointment date. Telephone No.: Facsimile No.: E-Mail Address: Mobile Tel. No.: 5D-E-248 American LegalNet, Inc. www.USCourtForms.com