[  ] Plaintiff 
[  ] Attorney for the Plaintiff and my Utah Bar number is _______ 

In the Justice Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

_____________________________________ 
Plaintiff 

Interpleader Affidavit and Summons 

_______________________________ 
Case Number 

_____________________________________ 
Defendant 

_______________________________ 
Judge 

_____________________________________ 
Defendant 

 

I swear that the following is true. 

(1) 

I am holding $________________ because 

Interpleader Affidavit and Summons 

Approved Board of Justice Court Judges September 22, 2010 
Revised May 10, 2017 

Page 1 of 4 

 
Name 

ddress 

ity, State, Zip 

  A

  C

  P

  E

 

hone 

mail 

 
I am the 
 

v. 

And 

       

 

(2) 

Defendants each say or may say that they each should have the money. 

(3) 

[  ]   Defendants reside within the jurisdiction of the court. 

[  ]  

The events happened within the jurisdiction of the court. 

(4) 

[  ]   Plaintiff has paid the money into court. 

[  ]    Plaintiff will pay the money as directed by the court. 

(5) 

[  ] 

I am filing this affidavit in the First District Court for Cache County because 
the defendant resides in unincorporated Cache County or in a municipality 
within Cache County that does not have a justice court and the cause of 
action arose in unincorporated Cache County or in a municipality within 
Cache County that does not have a justice court. 

I understand that I have the right to file this case in the district court where I 
could ask for a jury trial. By deciding to file this case in the justice court, I waive 
my right to a jury trial. 

I have not included any non-public information in this document. 

Date: 

 

Sign here ► 

Printed Name. Plaintiff or Plaintiff’s Agent 

 

On this date, I certify that _________________________________________________________ (name) 
who is known to me or who presented satisfactory identification, in the form of 
______________________________________________________ (form of 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 

 

 

 

Interpleader Affidavit and Summons 

Approved Board of Justice Court Judges September 22, 2010 
Revised May 10, 2017 

Page 2 of 4 

 

 

 

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. 

Se le cita a comparecer a juicio para responder al reclamo arriba descrito. El juicio 
tendrá lugar en la dirección del tribunal que se muestra arriba. Si usted no 
comparece, se podría dictar un fallo contra usted por el total de la cantidad 
reclamada. 

Date (Fecha) 

Room (Sala) 

 

 

Time (Hora) 

: 

[  ] a.m.  [  ]  p.m. 

[  ] p.m. 

Judge (Juez) 

 

Notice to the Defendant 

   

 

The State of Utah to the Defendants: 

Summons 

A small claims case has been filed against you. This imposes upon you certain rights and 
responsibilities. You can find small claims information and instructions at 
https://www.utcourts.gov/howto/smallclaims/. 

The court’s Finding Legal Help web page (www.utcourts.gov/howto/legalassist/) 
provides information about the ways you can get legal help, including the Self-Help Center, 
reduced-fee attorneys, limited legal help and free legal clinics. 

Un caso de reclamos menores ha sido presentado contra usted. Esto le impone a 
usted ciertos derechos y obligaciones.  Usted puede encontrar información e 
instrucciones sobre reclamos menores en 
https://www.utcourts.gov/howto/smallclaims/. 

La página del tribunal sobre Como Encontrar Ayuda Legal 
(www.utcourts.gov/howto/legalassist/) proporciona información acerca de las 
maneras en que usted puede obtener ayuda legal, incluyendo el Centro de Ayuda 
del tribunal, abogados a precio reducido, ayuda legal limitada y talleres jurídicos 
gratuitos. 

Attendance. You must attend. If you do not attend, the relief requested might be granted. 
You have the right to be represented by a lawyer. 

Asistencia. Presentarse es obligatorio. Si usted no llegara a presentarse, el 
remedio solicitado podría ser otorgado.  Usted tiene el derecho de que lo represente 

Interpleader Affidavit and Summons 

Approved Board of Justice Court Judges September 22, 2010 
Revised May 10, 2017 

Page 3 of 4 

 

un abogado. 

Evidence. Bring with you any evidence that you want the court to consider. 

Pruebas. Traiga con usted cualquier prueba que quiera que el tribunal tome en 
cuenta. 

Interpretation. If you do not speak or understand English, contact court staff at least 3 
days before the hearing, and an interpreter will be provided. 

Interpretación. Si usted no habla ni entiende el Inglés contacte al personal del 
tribunal por lo menos 3 días antes de la audiencia y le proveerán un intérprete. 

Disability Accommodation. If you have a disability requiring accommodation, including an 
ASL interpreter, contact court staff at least 3 days before the hearing. 

Atención en caso de incapacidades. Si usted tiene una incapacidad por la cual 
requiere atención especial, favor de contactar al personal del tribunal por lo menos 
3 días antes de la audiencia.   

Right to Jury Trial. If you want to have a jury trial in this case, you must file documents to 
remove the case to district court. See the Small Claims web page for information about that 
process, and forms: https://www.utcourts.gov/howto/smallclaims/. 

El derecho a juicio por jurado. Si usted quiere tener un juicio con jurado, usted 
deberá presentar documentos pidiendo que el caso sea transferido al tribunal de 
distrito. Vea la página de internet de Reclamos Menores para más información 
sobre el proceso y formularios: https://www.utcourts.gov/howto/smallclaims/. 

 

 

Sign here ► 

Court Clerk 

 

 

Interpleader Affidavit and Summons 

Approved Board of Justice Court Judges September 22, 2010 
Revised May 10, 2017 

Page 4 of 4 

 

Date: