My Name Address City, State, Zip Phone E-mail I am the Plaintiff Attorney for the Plaintiff and my Utah Bar number is _______
In the
District
Justice Court of Utah
__________ Judicial District ________________ County Court Address ______________________________________________________ _____________________________________ Affidavit and Summons
Plaintiff
Case Number ___________________ v. Judge _________________________ _____________________________________
Defendant
And _____________________________________
Defendant
I swear that the following is true. (1) Defendant owes me plus the filing fee of plus an estimated service fee of for a total of: $ $ $ $ for the claim described in paragraph (2).
plus prejudgment, if qualified for prejudgment interest.
Affidavit and Summons
Approved Board of District Court Judges September 10, 2008
Page 1 of 3
(2)
The events happened on _________________________ (date). My claim is based on the following facts.
(3) (4) (5)
Defendant resides within the jurisdiction of the court. The events happened within the jurisdiction of the court. I am not suing a government entity. I am not suing a government employee for the employee's on-the-job conduct. I am not suing on a claim that has been assigned to me.
I have not included any non-public information in this document. Date: Sign here Printed Name of Plaintiff or Plaintiff's Agent
I certify that __________________________, who is known to me or who presented satisfactory identification, has, while in my presence and while under oath or affirmation, voluntarily signed this document and declared that it is true. Date: Sign here Notary or Court Clerk Notary Seal
Affidavit and Summons
Approved Board of District Court Judges September 10, 2008
Page 2 of 3
Summons
The State of Utah to the Defendant(s):
You are summoned to appear at trial to answer the above claim. The trial will be held at the court address shown above. If you fail to appear, judgment may be entered against you for the total amount claimed. Date Room Notice to the Defendant. A small claims case has been filed against you. This imposes upon you certain rights and responsibilities. You may obtain small claims information and instructions at www.utcourts.gov/howto/ Disability Accommodations. If you need accommodation of a disability, contact a judicial service assistant at least 3 days before the hearing.
Date: Sign here Court Clerk
Time
:
a.m.
p.m.
Affidavit and Summons
Approved Board of District Court Judges September 10, 2008
Page 3 of 3