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Statement of Claim and Notice of Disagreement

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STATEMENT OF CLAIM AND NOTICE

(DISAGREEMENT ABOUT SECURITY DEPOSIT - RESIDENTIAL)

IN THE DISTRICT COURT OF THE FIFTH CIRCUIT

LIHU'E DIVISION

STATE OF HAWAI'I

Plaintiff(s)

Form #5DC05

Reserved for Court Use

Civil No.

Defendant(s)

Filing Party Name, Attorney, Address, Telephone and Fax Number

STATEMENT OF CLAIM

Plaintiff alleges as follows:

I am a resident of

Since (date) , 20, Defendant owes me the sum of $ for

Defendant resides and/or does business at

in the state of Hawai'i.

Plaintiff asks for judgment in the principal amount of $ .

In addition, the Court may award court costs and interest. Where the Court determines that the landlord WRONGFULLY and WILLFULLY retained all or part of the security deposit, it MAY award the tenant damages equal to three times the security deposit retained, pursuant to Hawaiʻi Revised Statutes §521-44(h).

DECLARATION

I DECLARE UNDER PENALTY OF PERJURY THAT THE FOLLOWING IS TRUE AND CORRECT.

Signature of Plaintiff:

Date:

Print/Type Name:

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

NOTICE

TO

This Statement of Claim will be heard by a Judge at the address checked below on

Monday, 20 at 8:45 a.m.

YOU MUST BE PRESENT ON THIS TRIAL DATE TO AVOID JUDGMENT BY DEFAULT.

COURT ADDRESS

District Court of the Fifth Circuit

Pu'uhonua Kaulike

Courtroom #2

3970 Kāʻana Street

Līhu'e, Hawai'i 96766

Mailing Address for the court: 3970 Kāʻana Street, Suite 207, Līhu'e, Hawaiʻi 96766-1282

If you have witnesses, or documents related to this claim, you should bring them with you to trial.

If you wish to subpoena witnesses for trial, contact the clerk as soon as possible before trial.

You may not be represented by an attorney in the Small Claims Division for security deposit cases.

You have NO RIGHT TO APPEAL from a judgment of the Small Claims Division.

IF YOU DO NOT APPEAR AND DEFEND ON THE DATE AND TIME STATED ABOVE, A DEFAULT JUDGMENT MAY BE ENTERED AGAINST YOU FOR THE AMOUNTS REQUESTED IN THIS STATEMENT OF CLAIM.

Clerk

This notice shall not be personally delivered between 10:00 p.m. and 6:00 a.m. on premises not open to the public, unless the court permits, in writing on this notice, personal delivery during those hours.

♿

In accordance with the Americans with Disabilities Act, and other applicable State and Federal laws, if you require an accommodation for your disability when working with a court program, service, or activity please contact the Deputy Chief Court Administrator's Office at PHONE NO. (808) 482-2347, FAX (808) 482-2509, OR TTY (808) 482-2533 at least (10) working days in advance of your hearing, or appointment date.

REPROGRAPHICS (01/10) RevaComm 508 Certified

Page 1 of 2

5D-E-248

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What the Statement of Claim and Notice of Disagreement Is

A Statement of Claim and Notice of Disagreement is a formal written filing used to register an objection to an adverse administrative or agency determination and to set out the factual and legal grounds for that objection. The document identifies the parties, cites the original decision or claim number, describes the specific findings being contested, lists supporting evidence, and states the relief or remedy requested. Filing it creates an official record that triggers procedural steps, service requirements, and statutory or agency deadlines for review or appeal.

Why a Clear Statement of Claim and Notice of Disagreement Matters

Filing a Statement of Claim and Notice of Disagreement preserves your rights, creates a focused record for reviewers, and starts any statutory appeal or reconsideration timelines. It helps agencies and tribunals identify disputed issues and the evidence you rely on, reducing procedural delay and limiting scope disputes during hearings.

Why a Clear Statement of Claim and Notice of Disagreement Matters

Who Typically Prepares and Files This Document

Common users include claimants, authorized representatives, and attorneys who need to document an objection to an administrative decision.

  • Individual claimants disputing benefit denials who need a written record to preserve appeal rights
  • Licensed attorneys representing clients in administrative appeals and drafting procedural statements
  • Organizational representatives filing on behalf of a business entity to contest regulatory findings

Core Parts of a Professional Statement of Claim and Notice of Disagreement

A well-structured Statement of Claim and Notice of Disagreement separates identity and case header, a numbered account of disputed findings, legal authority, evidence references, a precise remedy request, and signature and service information to support enforceability and review.

Case Header

Include claimant and respondent names, claim or docket number, original decision date, and contact details to ensure correct routing and processing by the receiving office.

Statement of Disagreement

Number each contested finding, describe why it is wrong, and tie each point directly to facts in the record to make issues clear for reviewers.

Legal Basis

Identify statutes, regulations, or agency rules that support your position and explain how they apply to the disputed facts rather than relying on general assertions.

Evidence List

Provide an exhibit index with brief descriptions, dates, and attachments; reference exhibit numbers in the narrative so reviewers can verify claims quickly.

Requested Remedy

Specify the relief sought for each contested finding (reversal, recalculation, reconsideration, or hearing) and provide concrete calculations where applicable.

Signature Block

Provide printed name, capacity, signature, date, and service address. If signing for a third party, attach authority documentation such as power of attorney or bar identification.

Essential Information You Must Provide

Claimant Name: Enter full legal name as shown on government ID
Respondent: Agency or respondent legal name
Claim Number: Include agency docket or claim identification
Decision Date: Use MM/DD/YYYY for the original determination date
Grounds Claimed: List specific factual and legal bases
Attachments: List and attach supporting exhibits

Step-by-Step: Preparing and Filing the Statement

Follow these steps to prepare, sign, serve, and preserve a Statement of Claim and Notice of Disagreement so you meet agency rules and retain proof needed for appeals or hearings.

  • 01
    Prepare Document: Draft dispute, list exhibits, and cite law
  • 02
    Check Deadlines: Confirm statutory and agency appeal dates
  • 03
    Sign and Verify: Sign under penalty of perjury if required
  • 04
    File and Serve: Submit per agency rules; retain proof of service

Configuring an Online Workflow for Filing and Service

Set up an online workflow to collect signatures, attach exhibits, capture audit trails, and produce proof of service consistent with agency requirements.

Field Configuration
Authentication Method Email link or SMS code
Signature Type Typed, drawn, or digital PKI
Attachment Handling Allow multiple PDF uploads
Audit Trail Enable IP, timestamp, and action logs

Typical Filing Flow from Draft to Acknowledgement

The usual flow is: prepare the submission, assign signers, authenticate identities, deliver to the agency or opposing party, and capture confirmation and audit records.

  • Upload: Add the completed Statement and exhibits as PDFs
  • Assign Signers: Add parties and representative emails with signing order
  • Authenticate: Use email, SMS, or stronger identity checks as required
  • Deliver: File via agency e-portal or serve by certified mail

Technical and Security Considerations for eFiling

Choose a platform that supports PDF, Word, robust audit trails, secure storage, and exportable signed records to meet evidentiary requirements.

  • Supported Formats: PDF, DOCX, HTML supported
  • Integrations: Connects to Google Workspace, NetSuite, Salesforce
  • Security Standards: AES-256 at rest, TLS 1.2/1.3

Typical Timelines and What to Expect After Filing

Exact deadlines vary by agency and statute. Typical administrative appeal windows run from 30 to 180 days; agencies often acknowledge receipt within days to a few weeks.

Initial Disagreement Deadline:

Often 30–60 days from decision receipt

Request for Reconsideration:

Some agencies allow 30–90 days for reconsideration

Hearing Request Window:

Request hearing within statutory period, commonly 60–180 days

Agency Acknowledgement:

Agency typically acknowledges receipt within 7–30 days

Appeal to Court:

Court filing often requires exhaustion of administrative remedies first

Penalties and Risks of an Incorrect or Untimely Filing

Missed Deadlines: Waiver of appeal rights
Incorrect Identifiers: Misrouted or rejected filings
Insufficient Evidence: Weakened dispute case
Improper Service: Lack of proof of service
False Statements: Potential perjury penalties
Data Exposure: HIPAA or privacy breach risk

eSignature Provider Pricing and Capability Snapshot

High-level price and capability comparison to help evaluate eSignature platforms for preparing, signing, and storing Statements of Claim and Notices of Disagreement.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes, 7-day trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No envelope cap 100 envelopes/user/year Varies Varies Varies

Frequently Asked Questions and Practical Answers

Answers to common questions about preparing, signing, filing, and preserving a Statement of Claim and Notice of Disagreement for administrative or agency disputes.


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