Statement of Claim and notiCe (general form) in the diStriCt Court of the fifth CirCuit li hu`e diviSion Form #5DC06 State of hawai`i Plaintiff(s) Reserved for Court Use Defendant(s) Civil No. Filing Party/Attorney Name, Attorney Number, Firm Name (if applicable) Address, Telephone and Fax Number. Statement of claim Plaintiff alleges as follows: I am a resident and/or do business at Since (date) , 20 , Defendant owes me the sum of $ for . Defendant resides and/or does business at in the state of Hawai`i. . Plaintiff asks for a judgment in the principal amount of $ In addition, Plaintiff asks for an award of interest, costs and fees as deemed reasonable and allowed by the Court. Declaration i Declare UnDer PenaltY of PerJUrY tHat WHat i HaVe StateD aBoVe iS trUe anD correct. Signature of Declarant: Date: Print/Type Name: 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 (01/10) CommonLook® 508 Certified page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 5d-e-250 notice to this Statement of claim will be heard by a Judge at the address checked below on monday, 20 at 8:45 a.m. : YoU mUSt Be PreSent on tHiS trial Date to aVoiD JUDGment BY DefaUlt. coUrt aDDreSS District Court of the Fifth Circuit Pu`uhonua Kaulike Courtroom #2 3970 Ka`ana Street Lihu`e, Hawai`i 96766 mailing address for the court: 3970 Ka`ana Street, Suite 207, Lihu`e, Hawai`i 96766-1282 If you have witnesses, or documents related to this claim, you should bring them with you to trial. If you wish to subpoena witnesses for trial, contact the clerk as soon as possible before trial. You may come with or without an attorney. A Small Claims case cannot be transferred to the Regular Claims Division unless the Plaintiff agrees to the transfer and the Regular Claims filing fee is paid to the Court. If a counterclaim is for more than $5,000.00, either party may demand a jury trial, pay the jury demand fee, and the case will be transferred to the Circuit Court You have NO RIGHT TO APPEAL from a judgment of the Small Claims Division. IF YOU DO NOT APPEAR AND DEFEND ON THE DATE AND TIME STATED ABOVE, A DEFAULT JUDGMENT MAY BE ENTERED AGAINST YOU FOR THE AMOUNTS REQUESTED IN THIS STATEMENT OF CLAIM. Clerk 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 the court permits, in writing on this notice, personal delivery during those hours. In accordance with the americans with Disabilities act , and other applicable State and Federal laws, if you require an accommodation for your disability when working with a court program, service, or activity please contact the Deputy Chief Court Administrator's Office at PHONE NO. (808) 482-2347, FAX (808) 482-2509, OR TTY (808) 482-2533 at least (10) working days in advance of your hearing, or appointment date. Clear form RepRogRaphics (01/10) CommonLook® 508 Certified page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com 5d-e-250