Small Claims General statement of claim and notice
In the Small Claims Division of the
District Court of the First Circuit
_________________________________ Division
State of Hawaiʻi
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.
Please read these instructions before you start the form
Case number:
This form is 3 pages and has 2 parts:
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
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
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.
Your name,
number, and
Your attorney’s
name, attorney
number, firm
name, address,
number, and
number, and
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 (05/2020) RL
Choose One
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
(Attach another sheet
if you need more
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.
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.
Today’s date:
Part II
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.
(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:
Honolulu Division Kauikeaouli Hale - 1111 Alakea Street, Honolulu – 10th Floor
Ewa Division 870 Fourth Street, Pearl City, Honolulu, Hawaii
Koolaupoko/Koolauloa Division 45-939 Pookela Street, Kāneohe, Hawaii
Wahiawā or Waialua Division 1034 Kilani Avenue, Wahiawā, Hawaii
Waianae Division 4675 Kapolei Parkway, Kapolei, Hawaii
Date & time:
If you need to mail or deliver anything to the Court, use this address, even if your hearing is at another location:
1111 Alakea Street, Honolulu, Hawaii 96813 – Third Floor
Today’s date:
Clear form
Here is more information to help both parties prepare for the hearing.
What if I don’t come to the hearing?
If you are the Defendant and you do not come to the hearing on the date and time shown above, the
Court may order you to pay the Plaintiff the amount requested in the Statement of Claim. This is called
a Default Judgment.
If you are the Plaintiff and you do not come to the hearing, the Court may dismiss your case.
May I hire an attorney?
Yes. You may come to the hearing with or without an attorney.
May I bring witnesses and documents to support my case to the hearing?
Yes. If you plan to question witnesses, they must come to the hearing at the date and time shown
You may also ask the Judge to look at documents that support your case. You must bring those
documents, with at least 2 copies, to the hearing.
How can I make sure my witnesses show up for the hearing?
The Court can help you make sure a witness comes to the hearing by issuing a subpoena. If you wish to
subpoena witnesses, contact the Court Clerk as soon as possible before the hearing.
How can I get the case moved to a different court?
A small claims case can only be transferred to the Court’s Regular Claims Division if the Plaintiff agrees
to the transfer. If the Plaintiff agrees to the transfer, you must pay the regular claims filing fee to this
Defendant, if you file a counterclaim for more than $5,000, then either you or the Plaintiff may ask for a
jury trial. Once the jury fee is paid, the Court will decide if the case should be transferred to the Circuit
If I lose the case, may I appeal it?
No. In a small claims action, the Judge’s decision is final. You MAY NOT appeal a judgment of the Small
Claims Division.
Instructions to the Plaintiff about delivering this form to the Defendant
You must deliver a full copy of this form to the Defendant, either by registered or certified mail, with restricted
delivery, or by personal service. Please read the Instructions on the Service of Process Information Sheet
carefully before you try to serve the Defendant.
Restriction on personal service: This claim may not be personally delivered between 10:00 p.m. and 6:00 a.m.
unless it is served at a location that is open to the public, or unless a Judge of this Court, by written order,
permits personal delivery during those hours.
Americans with Disabilities Act Notice
If you need an accommodation for a disability when participating in a court program, service or activity, please
contact the ADA Coordinator as soon as possible to allow the court time to provide an accommodation:
Call (808) 538-5121; or
Send an e-mail to
The court will try to provide, but cannot guarantee, your requested auxiliary aid, service or accommodation.
If you need help with this document, please contact the District Court Service Center at PHONE NO. (808) 538-5629 VISIT
1111 Alakea Street, Third Floor.