Statement Of Claim And Notice (Disagreement About Security Deposit-Residential) {3DC05}

Statement of ClaIm anD notICe (DISagreement about SeCurIty DepoSIt - reSIDentIal) In the Small ClaImS DIvISIon of the DIStrICt Court of the thIrD CIrCuIt DIvISIon Form #3DC05 State of hawaI`I Plaintiff(s) Reserved for Court Use Civil No. Defendant(s) Filing Party Name, Attorney, Address, Telephone and Fax Number Statement of claim Plaintiff alleges as follows: I am a resident 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 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 security deposit retained, pursuant to Hawai`i Revised Statutes §521-44(h). DeclaRation i DeclaRe UnDeR PenaltY of PeRJURY tHat tHe folloWinG iS tRUe anD coRRect. Signature of Plaintiff: 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 (04/12) page 1 of 2 sTaTeMeNT oF cLaiM aND NoTice (Residential) 3D-p-299 American LegalNet, Inc. www.FormsWorkFlow.com notice to this Statement of claim will be heard by a Judge at the address checked below on , 20 at m. : YoU mUSt Be PReSent on tHiS tRial Date to aVoiD JUDGment BY DefaUlt. coURt aDDReSS north & South Hilo Division 777 Kilauea Avenue, 2nd Floor, Hilo, Hawai`i 96720-4212 Puna Division 777 Kilauea Avenue, 2nd Floor, Hilo, Hawai`i 96720-4212 north & South Kona Division 79-1020 Haukapila Street, Kealakekua, Hawai`i 96750 - Division -- To be heard at North & South Kona Division Ka`u Kona: 79-1020 Haukapila Street, Kealakekua, Hawai`i 96750 q South Kohala Division 67-5187 Kamamalu Street, Kamuela, Hawai`i 96743 - ma kua Division -- To be heard at South Kohala Division q Ha 67-5187 Kamamalu Street, Kamuela, Hawai`i 96743 q north Kohala Division -- To be heard at South Kohala Division 67-5187 Kamamalu Street, Kamuela, Hawai`i 96743 q q q q mailing address for the court: q 777 Kilauea Avenue, Hilo, Hawai`i 96720-4212 q 79-1020 Haukapila Street, Kealakekua, Hawai`i 96750 q 67-5187 Kamamalu Street, Kamuela, Hawai`i 96743 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 not be represented by an attorney in the Small Claims Division for security deposit cases. 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 District Court Administration Office at PHONE NO. 961-7424, FAX 961-7411, OR TTY 961-7422 at least (10) working days in advance of your hearing, or appointment date. RepRogRaphics (04/12) page 2 of 2 sTaTeMeNT oF cLaiM aND NoTice (Residential) 3D-p-299 American LegalNet, Inc. www.FormsWorkFlow.com