Haw. R. Civ. P. Form 29

(Your name)

(Your address)

(Your telephone number)

IN THE CIRCUIT COURT OF THE (insert the judicial circuit no.) CIRCUIT

STATE OF HAWAIʻI

(Your Name), ) Civil No.

)

Appellant, ) Agency Docket/Case No.

)

v. )

) NOTICE OF APPEAL TO THE CIRCUIT

(Name of governmental official or agency, ) COURT; STATEMENT OF THE CASE;

whose order or decision is being appealed); ) EXHIBIT A; DESIGNATION OF RECORD ON

(Name(s) of any other party to the proceeding ) APPEAL; ORDER FOR CERTIFICATION AND

before the official or agency), ) TRANSMISSION OF RECORD; CERTIFICATE

) OF SERVICE

Appellee(s). )

)

NOTICE OF APPEAL TO THE CIRCUIT COURT

Notice is hereby given that (Your Name), Appellant above-named, pursuant to section (list statutes that give the right to appeal the order or decision), Hawaiʻi Revised Statutes, and Rule 72 of the Hawaiʻi Rules of Civil Procedure, hereby appeals to the Circuit Court of the (insert the judicial circuit no.) Circuit from the (order or decision) of (Name of governmental official or agency whose order or decision is being appealed) entered on (Date of order or decision). A copy of the (order or decision) is attached as Exhibit A.

DATED: (Name of the City you are in), (State), (Date document is signed).

(Your signature)

(Print or Type your name here)