Free Complaint (Personal Injury) - Hawaii

COMPLAINT (PERSONAL INJURY/ PROPERTY DAMAGES); SUMMONS IN THE DISTRICT COURT OF THE THIRD CIRCUIT ______________________________ DIVISION STATE OF HAWAI`I
Plaintiff(s)

Form #3DC09

Reserved for Court Use

Civil No. Plaintiff(s)/Plaintiff(s)' Attorney (Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Facsimile Numbers)

Defendant(s)

Date of Injury/Damage: COMPLAINT This Court has jurisdiction over this matter and venue is proper. On or about the date of injury/damage stated above, Defendant(s) intentionally and/or negligently injured Plaintiff(s) and/or damaged Plaintiff(s)' property by: (state location of incident and briefly explain what happened)

1. 2.

3.

As a result of the incident, Defendant(s) caused the following damages: G Physical Injury (Do not state the dollar amount, but give a brief description of the damage):

G

Property Damage in the amount of $

(Explain the type of damage):

4. 5.

Defendant(s) has refused to pay for Plaintiff(s)' damages. Plaintiff(s) asks for judgment against Defendant(s) for the damages proved. In addition, the Court may award court costs, interest and reasonable attorney's fees. Signature of Plaintiff(s)/Plaintiff(s)' Attorney:

Date:

Print/Type Name:

In accordance with the Americans with Disabilities Act if you require an accommodation for your disability, please contact the ADA Coordinator at PHONE NO. 934-5788, FAX 935-1959, or TTY 961-7525 at least ten (10) working days in advance of your hearing or appointment date.
COMPPI.X (Amended 4/18/97)v
3D-P-262

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 (11/06)

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