Free Statement of Claim (General Form) - Hawaii


File Size: 451.0 kB
Pages: 2
Date: August 18, 2008
File Format: PDF
State: Hawaii
Category: Court Forms - State
Author: Unknown
Word Count: 615 Words, 4,862 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.state.hi.us/jud/Kauai/District/5soc-gf.pdf

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Preview Statement of Claim (General Form)
Statement of Claim and notiCe (General form)
in the Small ClaimS diviSion of the diStriCt Court of the fifth CirCuit State of hawai`i
Plaintiff(s)

Form #5DC48B

Reserved for Court Use

Defendant(s)

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

Plaintiff(s) alleges as follows: ___he is/are a resident(s) of ______________________________________________________________________________________ Since __________________________ , 20 ______, the defendant(s) owes/owe plaintiff(s) the sum of $ _______________________ for _________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ 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. 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 (08/08) socgF 5D-e-250

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 ______________ day of ____________________________________ , 20 ____________ ____________________________________________________ Notary Public, State of _________________________________ My commission expires: ________________________________ Clerk of the above-entitled Court Print/Type Name of Affiant 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 ________________________________ ,_______________________, 20 _______ at____ thereafter as parties may be heard. . M, or as soon

YOU ARE REQUIRED TO BE PRESENT ON THIS TRIAL DATE TO AVOID JUDGMENT BY DEFAULT. COURT ADDRESS
District Court of the Fifth Circuit Kaua`i Judiciary Complex Courtroom #2 3970 Ka`ana Street ¯ ¯ L1 hu`e, Hawai`i 96766-1282 Mailing address for the above Court: 3970 Ka`ana Street, Suite 207, L1 hu`e, Hawai`i 96766-1282. ¯ ¯

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 come with or without an attorney. You have no right to APPEAL if the case remains in the Small Claims Division. A Small Claims case cannot be transferred to the Regular 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 $325.00 to the clerk of the Court. 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. 482-2347, FAX 482-2509, OR TTY 482-2533 at least (10) working days in advance of your hearing or appointment date.
RepRogRaphics (08/08) socgF 5D-e-250

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