COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... .. . .. STATEMENT. OF. C.LAIM AND NOTICE (GENERAL FORM) : IN THE SMALL CLAIMS DIVISION OF THE DISTRICT COURT OF THE FIFTH CIRCUIT ______________________________ DIVISION STATE OF HAWAI‘I Plaintiff(s) Plaintiff(s) TWO-SIDED FORM Index No. Form #5DC48B : : -against- Calendar No. JUDICIAL SUBPOENA : : : Defendant(s) : ...................................................... Reserved for Court Use Defendant(s) THE PEOPLE OF THE STATE OF NEW YORK Civil No. TO Filing Party(ies)/Filing Party(ies)' Attorney Name, Attorney Number,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 , at the Court located at County of he is/are a resident and/or does/do business at of in room , on the day , 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 Plaintiff(s) alleges as follows: the Honorable Since , 20 , the defendant(s) owes/owe the 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, interest. c:\wp51\wpdoc\soc.2x\10/1/97v 5D-E-250 (04/03) . Office and P.O. Address 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). : JUDICIAL SUBPOENA Plaintiff(s)Signature of Affiant: day of Subscribed and sworn to before me this -against- : , 20 : Print/Type Name of Affiant: : Notary Public, State of Defendant(s) of the above-entitled Court : Clerk ...................................................... My commission expires: NOTICE TO: : THE PEOPLE OF THE STATE OF NEW YORK Please take notice that this Statement of Claim will be heard 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 GREETINGS: G Lihue Division 3461 Weliweli Road, Koloa, Hawai‘i 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 , the Honorable at the Court G Waimea Division 3461 Weliweli Road, Koloa, Hawai‘i located at Kuhio Highway, Hanalei, Hawai‘i County of G Hanalei Division 5-5358 in room , on the day of , 20 , at o'clock in the noon, and at any recessed Mailing address for the above Courts: 4357 Rice Street, Suite 101, Lihue, in this action on the part of the or adjourned date, to testify and give evidence as a witness Hawai‘i 96766-1367 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 the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a If you admit the claim, but desire additional time to pay, you must come to the trial in person and state the circumstances to the Court. result of your failure to comply. You may come with or without an attorney. Witness, Honorable , one of the Justices of the You have no right to APPEAL ifCounty, remains in of Small Claims Division. A Small Claims case cannot be transferred to the Regular the case Court in day the , 20 Claims Division unless the plaintiff agrees to the transfer and payment of a fee to the clerk of the Court. If the 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 (Attorney must sign above and type name below) $325.00 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. Attorney(s) for Clerk of the above-entitled Court Office and P.O. Address 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 Telephone No.: District Court Administration Office at PHONE NO. 246-3347, FAX 246-3353, or TTY 539-4853 at least ten (10) working days Facsimile No.: in advance of your hearing or appointment date. E-Mail Address: 5D-E-250 Mobile Tel. No.: American LegalNet, Inc. www.USCourtForms.com