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- Form DL-14 "Statement of Complaint" - Hawaii
Form DL-14 "Statement of Complaint" - Hawaii
What Is Form DL-14?
This is a legal form that was released by the Hawaii Department of Agriculture - a government authority operating within Hawaii. As of today, no separate filing guidelines for the form are provided by the issuing department.
Form Details:
- Released on March 1, 2016;
- The latest edition provided by the Hawaii Department of Agriculture;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of Form DL-14 by clicking the link below or browse more documents and templates provided by the Hawaii Department of Agriculture.
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5DL-14
03/16
Commodities Branch
1851 Auiki Street
Honolulu, Hawaii 96819-3100
Phone: (808) 832-0700
STATEMENT OF COMPLAINT
Concerning An Alleged Violation of Chapter 145, Hawaii Revised Statutes
(Regulation of Dealers in Farm Produce)
COMPLAINANT – Farmer/Producer
RESPONDENT
(Complaint made by)
(Party complained against)
Name
Company Name
Title
dba
Company Name
Address
dba
City, State, Zip
Address
Contact Person
City, State, Zip
Title
Phone
Cell
Phone
I, ____________________________________, complainant, whose address appears above, hereby state that:
1. I delivered to _________________________________________, respondent, farm produce as specified
below, grown and produced by complainant within the State of Hawaii.
2. Respondent took possession of the farm produce from complainant and has failed to pay to complainant,
the full purchase price within the time and in the manner agreed upon as stated below.
3. The indebtedness of the respondent to the complainant is $______________ which is now due.
4. The following are supportive facts to these claims:
A. The reason for filing this complaint is:
(1) Nonpayment
(2) Payments being made are not in accordance with agreement
(3) Respondent claims payment in full was made but amount received is less than agreement
B. The type and quantity of farm product involved is: ________________________
______________
(Type)
(Quantity)
C. The payment method was agreed upon through:
(1) Verbal agreement
(2) Written contract
(3) Letter
(4) Other – Specify _____________________________________________________________
What was the agreement? ___________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
D. The selling price was:
(1) Established before shipment
(2) The current market price
(3) Other – Specify _____________________________________________________________
DL-14
03/16
Commodities Branch
1851 Auiki Street
Honolulu, Hawaii 96819-3100
Phone: (808) 832-0700
STATEMENT OF COMPLAINT
Concerning An Alleged Violation of Chapter 145, Hawaii Revised Statutes
(Regulation of Dealers in Farm Produce)
COMPLAINANT – Farmer/Producer
RESPONDENT
(Complaint made by)
(Party complained against)
Name
Company Name
Title
dba
Company Name
Address
dba
City, State, Zip
Address
Contact Person
City, State, Zip
Title
Phone
Cell
Phone
I, ____________________________________, complainant, whose address appears above, hereby state that:
1. I delivered to _________________________________________, respondent, farm produce as specified
below, grown and produced by complainant within the State of Hawaii.
2. Respondent took possession of the farm produce from complainant and has failed to pay to complainant,
the full purchase price within the time and in the manner agreed upon as stated below.
3. The indebtedness of the respondent to the complainant is $______________ which is now due.
4. The following are supportive facts to these claims:
A. The reason for filing this complaint is:
(1) Nonpayment
(2) Payments being made are not in accordance with agreement
(3) Respondent claims payment in full was made but amount received is less than agreement
B. The type and quantity of farm product involved is: ________________________
______________
(Type)
(Quantity)
C. The payment method was agreed upon through:
(1) Verbal agreement
(2) Written contract
(3) Letter
(4) Other – Specify _____________________________________________________________
What was the agreement? ___________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
D. The selling price was:
(1) Established before shipment
(2) The current market price
(3) Other – Specify _____________________________________________________________
DL-14
Pg. 2
E. The payment method agreed upon was:
(1) Cash upon receipt of product
(2) Cash within 30 days
(3) Consignment sale
(4) Other – Specify _____________________________________________________________
F. The amount of claim was determined as follows:
(Include additional attachment if needed)
Invoice
Invoice
Quantity
Type of
Unit
Date
Number
Product
Price
(Net Wt. / Units)
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
Qty. Subtotal this page _________
Subtotal from this page
$_________
Subtotal attachment(s) _________
Subtotal from attachment(s)
$_________
Total Quantity _________
Total Value of Sales
$_________
Total interest @ _____% per ______
+ $_________
Payments to principal
- $_________
Payments to interest
- $_________
Total Claim
$_________
DL-14
Pg. 3
G. The interest being charged was agreed to in writing:
Yes
No
Not Applicable
H. If applicable, the last payment for this claim was received on: Date _________ Amount ___________
I.
Shipments of farm product were made as follows:
First Shipment date: ________________________________________________________________
Last Shipment date: ________________________________________________________________
Number of shipments: ______________________________________________________________
J. The quantity in each shipment was:
(1) Specified by respondent
(2) Unspecified
(3) Other – Specify _____________________________________________________________
What was the agreement? ___________________________________________________________
________________________________________________________________________________
K. Give a brief statement or list the attempts you have made to resolve your claim against the
respondent. (Indicate the personal visits made, calls made, letters written, invoices mailed, etc.
Indicate statements and promises made to you by the respondent.)
This statement is continued on _______ (number) additional pages.
DL-14
Pg. 4
L. I have attached copies of the following documents to substantiate items A to K:
(Do not send originals)
(1) Contract (written)
(2) Contract (our interpretation of the verbal agreement)
(3) Bill(s) of lading
(4) Invoices
(5) Letters
(6) Statements
(7) Promissory notes or other statements of collateral
(8) Other – Specify _____________________________________________________________
5. I understand I may be required to appear before a hearing officer at my own expense and present
originals of any supportive documents should this complaint result in a hearing concerning this alleged
violation.
6. I declare under penalty of perjury that the statements made above true and correct.
_____________________________
______________________________
________________
Print name of Complainant
Signature of Complainant
Date
Signature verified by: ___________________________________
Department Officer
NOTE: if complainant is unable to sign before a Department Officer, he/she is to sign before a Notary Public.
STATE OF HAWAII
)
SS
CITY AND COUNTY OF ________________________
)
On this _______________ day of _______________________________, 20____, before me personally
appeared ___________________________________________, who acknowledged and signed the forgoing
complaint as his/her free act and deed.
_________________________________
Notary Public, ________________Circuit
State of Hawaii
My commission expires: _____________
Filed: ________________________________, 20____
DL-14
Attachment
No. ____ of ____
Attachment sheet(s) for use with item 4.F. if needed.
Invoice
Invoice
Quantity
Type of
Unit
Date
Number
Product
Price
(Net Wt. / Units)
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
_______
_________
_________ of _________________ @ ________
= $_________
Total Quantity for this page
_________
Total Amount for this page
$_________
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DA Form 2062 "Hand Receipt/Annex Number"
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DD Form 2813
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DD Form 2977 "Deliberate Risk Assessment Worksheet"
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AF Form 910 "Enlisted Performance Report (AB Thru Tsgt)"
-
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DD Form 1750 "Packing List"
-
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