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________________________________________________ DECLARATION ON GARNISHEE TRANSFER; EXHIBIT(S) NOTICE TO EMPLOYER OF JUDGMENT DEBTOR; GARNISHEE INFORMATION Form 5DC33 IN THE DISTRICT COURT OF THE FIFTH CIRCUIT STATE OF HAWAI‘I Plaintiff Defendant Garnishee (Name and Address) Reserved for Court Use Civil No. Filing Party/Attorney Name, Attorney Number, Firm Name (if applicable), Address, Telephone and Fax Number or Email Certified copy of the Judgment attached as Exhibit A Current Amount Due: $ __ (If this amount is different from the Judgment Amount, please attach separate sheet showing calculations as Exhibit B) Former Employer: Current Employer: DECLARATION ON GARNISHEE TRANSFER I have read this Declaration, know the contents and verify that the statements are true to my personal knowledge and belief. I DECLARE UNDER THE PENALTY OF PERJURY THAT THE FOLLOWING IS TRUE AND CORRECT: 1. I am the Judgment Creditor or Judgment Creditor’s attorney; 2. The Judgment (a certified copy of which is attached as Exhibit A) was entered on the date shown on the Judgment for Judgment Creditor and against Judgment Debtor; 3. There is still due and owing; the amount shown in the copy of the Judgment attached as Exhibit A or the amount shown in the attached Exhibit B; I certify that this is a full, true, and correct copy of the original on filed in this office. Clerk, District Court of the above Circuit, State of Hawai‘i (Rev. 08/03/2011) Page 1 of 2 Form 5DC33 ________________________________ G G (continued on reverse side) 5D-P- 205 CommonLook ® Reprographics (09/11) 5D 508 Certified DECLARATION ON GARNISHEE TRANSFER (continued) 4. The Judgment has not been appealed (or if appealed, no bond has been filed), reversed, modified, set aside or satisfied except as aforesaid and otherwise remains in full force and effect; and 5. The Judgment Creditor is still the owner and holder of the Judgment. 6. Judgment Debtor has left the employment of the Former Employer listed and is now believed to be in the employment of the Current Employer listed. 7. A Garnishee Order has been granted against the Former Employer of Judgment Debtor listed. Date Signature of Declarant: Print/Type Name: NOTICE TO EMPLOYER OF JUDGMENT DEBTOR(S) PURSUANT TO HAWAI ‘I REVISED STATUTES §652-5, YOU ARE REQUIRED TO WITHHOLD IN AMOUNTS CONSISTENT WITH RATES PROVIDED FOR BY LAW, A PERCENTAGE OF THE JUDGMENT DEBTOR’S WAGES (INCLUDING ANY SALARY, STIPEND, COMMISSIONS, ANNUITY OR NET INCOME OR PORTION OF NET INCOME UNDER A TRUST), COMMISSIONS AND COMPENSATION AND PAY THESE FROM WEEK TO WEEK OR MONTH TO MONTH TO THE JUDGMENT CREDITOR UNTIL ALL SUMS DUE UNDER THE JUDGMENT ARE PAID. In accordance with the Americans with Disabilities 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 District Court Administration Office at PHONE NO. (808) 482-2347, FAX (808) 482-2509, or TTY (808) 482-2533 at least ten (10) working days before your proceeding, hearing, or appointment date. 5D -P- 205 (Rev. 08/03/2011) Page 2 of 2 Form 5DC33 CommonLook® 508 Certified