Free Statement of Claim (Security Deposit) - Hawaii

STATEMENT OF CLAIM AND NOTICE
[DISAGREEMENT ABOUT SECURITY DEPOSIT-RESIDENTIAL]

TWO-SIDED FORM Form #1DC48A

IN THE SMALL CLAIMS DIVISION OF THE DISTRICT COURT OF THE FIRST CIRCUIT ______________________________ DIVISION STATE OF HAWAI`I
Plaintiff(s)

Defendant(s)

Reserved for Court Use

Civil No. Filing Party(ies)' Name, Firm Name (if applicable), Address, Telephone and Facsimile Numbers

Plaintiff(s) alleges as follows: he is/are a resident(s) of Since for , 200 , the defendant(s) owes/owe plaintiff(s) the sum of $

Defendant(s) reside(s) and/or does/do business at 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. c:\wp51\wpdoc\soc.2x\10/1/97v
1D-P-1037 (05/03)

I do hereby certify that this is a full, true, and correct copy of the original on file in this office. Clerk, District Court of the First Circuit, State of Hawai`i

See REVERSE SIDE

AFFIDAVIT
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). Subscribed and sworn to before me this , 200 Print/Type Name of Affiant: Notary Public, State of My commission expires: Clerk of the above-entitled Court day of Signature of Affiant:

NOTICE
TO: Please take notice that this Statement of Claim will be heard by the District Judge of this Court, in his/her Courtroom, at the address checked below on , , 200 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 Honolulu Division 1111 Alakea Street, 10th Floor, 10A, Honolulu, Hawai`i 96813 G `Ewa Division 870 Fourth Street, Pearl City, Hawai`i G Ko`olaupoko OR Ko`olauloa Division 45-939 Po`okela Street, Kane`ohe, Hawai`i ¯ G Wahiawa OR Waialua Division ¯ 1034 Kilani Avenue,Wahiaw¯, Hawai`i a G Wai`anae Division 87-1784 Farrington Highway, Nanakuli, Hawai`i ¯ ¯ Mailing address for the above Courts: 1111 Alakea Street, Civil Division, Third Floor, Honolulu, Hawai`i 96813 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. 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. You may not be represented by an attorney in the Small Claims Division for security deposit cases. You have no right to APPEAL from the judgment of the Small Claims Division. 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. :

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.

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. 538-5121, FAX 538-5233, or TTY 539-4853 at least ten (10) working days in advance of your hearing or appointment date. For Civil related matters, please call 538-5151.
1D-P-1037

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