Filing Party Name
Filing Party Mailing Address
Filing Party Telephone Number
IN THE CIRCUIT COURT OF THE ____________ CIRCUIT
) Special Proceeding No.
I, the undersigned below and Respondent herein, am an
owner-occupant and mortgagor of an interest in the residential property described in the
petition and my interest is pledged or otherwise encumbered by the mortgage being
a person who signed the promissory note or other instrument evidencing the debt
secured by the mortgage being foreclosed.
I agree to submit myself to the judicial process and jurisdiction of the circuit court in this
conversion proceeding and any foreclosure proceeding that results therefrom.
_________________________, Hawai'i, _______________________________.
[Signature of Filing Party]
[Typed Name of Filing Party]
In accordance with the Americans with Disability Act, and other applicable State and Federal laws, if you require an accommodation for a disability
when working with a court program, service or activity, please contact the Circuit Court Administration Office on OAHU: Phone No.539-4400,
Fax 539-4402 , or TTY 539-4853; MAUI : Phone No. 244-2969, Fax 244-2932, or TTY 244-2865; HAWAII: Phone No. 961-7424, Fax
961-7411, or TTY 961-7422; KAUAI: Phone No. 482-2365. Fax 482-2509, or TTY 482-2533, at least 10 working days before your proceeding,
hearing or appointment date.
Form B - Submission Statement (05/11)