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__________________________________________________________
Small Claims – General Statement of Claim and Notice
(#2DC06)
In the Small Claims Division of the
District Court of the Second Circuit
_________________ Division
State of Hawai`i
Please read these instructions before you start the form
How to use this form
Use this form to file a small claims case if you believe someone owes you $5,000 or less.
When you file this form, you are called the Plaintiff. The person you want a judgment against is called the Defendant.
This form is 3 pages and has 2 parts:
Case number:
Part I: The Statement of Claim , including your sworn statement about your situation (called a Declaration ).
Fill out Part I to give the Court the details about your case and to tell the Court what you would like to happen.
Part II: A Notice of Hearing. The Court Clerk will use this part of the form to schedule a hearing for your case. At the hearing, you will be able to present evidence and tell the Judge why you should win this case. The Defendant will have the same opportunity.
When you have finished the form and the Court has scheduled a hearing, you must deliver a copy of the full form to the Defendant. You can find more information on the Service of Process Information Sheet.
Part I
STATEMENT OF CLAIM
1 Give the Court your contact information and as much of the Defendant’s contact information as you can. If you
have an attorney, give the Court your attorney’s contact information.
Defendant’s Your name, name, address, address, telephone telephone number, and number, and email: email:
Your attorney’s name, attorney number, firm name, address, telephone number, and email: Attorney signature
On the next page, you will give the Judge more information about your case and what you would like to happen. You will then sign a Declaration, swearing that the information in this form is true.
RG-AC-508 (06/2020) RL 2D-P-
2 Give the Court information about the money that the Defendant owes you.
The Defendant owes me this much money:
Month Day Year
The Defendant has owed me this money since this date:
This is why the Defendant owes me money: (Attach another sheet if you need more room.)
3 Read the information below and then sign the Declaration.
I would like the Court to order the Defendant to pay me the amount listed above. I would also like the Court to
order the Defendant to pay me interest, costs, and fees that the Court believes are just and reasonable.
PLAINTIFF’S D ECLARATION
The information in this claim is true and correct. I understand that I may be prosecuted for perjury if I
have stated anything in this form that I know is not true.
Your Today’s date: signature:
Part II
NOTICE OF H EARING
4
Fill in the Defendant’s name below and then take or mail the form to the Court. Court staff will schedule a
hearing and will fill out the rest of Part II then return it to you to serve.
To: (Defendant’s name)
The Plaintiff has filed this Statement of Claim. A Judge will hear arguments from both the Plaintiff and the Defendant at
the place and time stated here:
Place: [ ] Wailuku Division 2145 Main Street, Courtroom 3D, Third Floor, Wailuku, Hawai`i 96793
[ ] Lahaina Division 1870 Honoapiilani Highway, Lahaina, Hawaii 96761
[ ] Hana Division 4974 Uakea Road, Hana, Hawai`i 96713
[ ] Molokai Division 55 Makaena Place, Kaunakakai, Hawai`i 96748
[ ] Lanai Division 312 8 th^ Street, Lanai City, Hawai`i 96763
Date & time:
If you need to mail or deliver anything to the Court, use this address, even if your hearing is at another location:
2 nd^ Circuit Court
2145 Main Street, Room 106, Wailuku, Hawai`i 96793
Clerk’s Today’s date: signature:
(Rev. 5/2020)
SERVICE PROCESS INFORMATION SHEET
(SMALL CLAIMS)
IT IS THE PLAINTIFF’S RESPONSIBILITY TO EFFECT SERVICE. EACH DEFENDANT MUST BE SERVED
SEPARATELY, BY ONE OF THE FOLLOWING METHODS:
1) DISINTERESTED THIRD PARTY
Anyone who is 18 years of age or older and who is NOT a party to the Claim, may serve your
documents. The Disinterested Third Party, or you, will file the Return of Service as soon as the
Defendant is served.
2) PROCESS SERVER
Contact the 2 nd^ Circuit Service Center at (808) 244-2706 or 2145 Main Street, Room 141, Wailuku or
at the Website at dps.hawaii.gov for a current list of Process Servers, their fees may vary.
Contact a Process Server and make your own arrangements to have your Small Claims or Regular
Claims documents served upon the Defendant. The Process Server, or you, will file the Return of
Service as proof that the Defendant was served.
3) CERTIFIED MAIL
SMALL CLAIMS Take the certified copy of your Statement of Claim to the Post Office and mail to each
Defendant by Certified Mail, Restricted Delivery (addressee only), and Return Receipt Requested
(green card).
You can either file the Return Receipt (green card) and the Mail Cost Slip as proof of service or on the
day of your court, present the Return Receipt (green card) showing the date of delivery and the
signature of the Defendant and the Mail Cost Slip to the Clerk/Judge.
NOTE: If the Defendant is not served prior to the court date, you MUST still appear to obtain another
court date for service upon the Defendant.
4) SERVICE QUESTIONS
Please contact the Self-Help Center located on the 1 st^ floor of the courthouse at 2145 Main Street,
Wailuku. Hours of operation are:
Self-Help Center
Hours: Monday and Thursday
10:00 a.m. to 1:00 p.m.
