Free Statement of Claim (Security Deposit) - Hawaii

Statement of Claim and notiCe

Form #5DC48A

(diSagreement about SeCurity depoSit-reSidential)

in the Small ClaimS diviSion of the diStriCt Court of the fifth CirCuit State of hawai`i
Plaintiff(s)

Reserved for Court Use

Defendant(s)

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 __________________________ , 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. 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. 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) soc 5D-e-248

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 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. 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) soc 5D-e-248

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