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Here is the text we could read:

 
Name 
 
Address 
 
City, State, Zip 
 
Phone 

 
Email  

I am the 

 

If you do not respond to this 
document within applicable time 
limits, judgment could be entered 
against you as requested. 

 
 
 
 
 
 
 
Check your email. You will receive information and 
documents at this email address. 
 

[  ] Petitioner 
[  ] Attorney for the Petitioner and my Utah Bar number is _________ 

In the District Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

_____________________________________ 
Petitioner 

Petition for Judicial Review of Final 
Agency Action 

_______________________________ 
Case Number 

_____________________________________ 
Respondent 

_______________________________ 
Judge 

Petitioner states: 

(1) 

I am seeking judicial review of a final agency action in an informal adjudicative 
proceeding pursuant to Utah Code Section 63G-4-402 and 
______________________ (Utah Code or other citation).  

(2)  My name and mailing address are: 

v. 

 

     

Petition for Judicial Review of Final Agency 
Action 
 

Approved Board of District Court Judges May 18, 2015 
Revised February 8, 2021 

Page 1 of 4 

 

     

     

     

(4) 

The title and date of the final agency action to be reviewed are: 

A copy, summary, or brief description of the agency action is attached to this 
petition or provided here: 

(5) 

The identification of the persons who were parties in the informal adjudicative 
proceedings that led to the agency action are: 

 

 

 

 

 

(3) 

The name and mailing address of the responding agency are: 

(6) 

(7) 

A copy of the written agency order from the informal proceeding is attached to 
this petition. 

Venue is proper under Utah Code Section 63G-4-402(1)(b) and 
_______________________________ (cite to relevant Utah Code section, if any). 

(8) 

The facts demonstrating that I am entitled to obtain judicial review are: 

Petition for Judicial Review of Final Agency 
Action 
 

Approved Board of District Court Judges May 18, 2015 
Revised February 8, 2021 

Page 2 of 4 

       

 

 

 

   

(9) 

I request this court to order the following relief (choose all that apply): 

[  ] 

order agency action required by law. The agency action I want is:  

order the agency to exercise its discretion as required by law. I want the 

[  ] 
court to order the agency to  

[  ] 

set aside the agency action 

[  ]   modify the agency action in this way: 

[  ] 

[  ] 

[  ] 

enjoin or stay the effective date of agency action 

remand the matter to the agency for further proceedings 

other ______________________________________________________ 

(10)  The reasons why I am entitled to relief are: 

Petition for Judicial Review of Final Agency 
Action 
 

Approved Board of District Court Judges May 18, 2015 
Revised February 8, 2021 

Page 3 of 4 

 

 

 

 

 

 

 

 

 

 

 

 

(11) 

I request a trial de novo in this matter. 

 

 declare under criminal penalty under the law of Utah that everything stated in this document is true. 

Signed at ______________________________________________________ (city, and state or country). 

Signature ► 

Printed Name 

 

 

    I

   

 
Date 

Petition for Judicial Review of Final Agency 
Action 
 

Approved Board of District Court Judges May 18, 2015 
Revised February 8, 2021 

Page 4 of 4

Petition for Judicial Review of Final Agency Action

This info page is part of the LIT Lab's Form Explorer project. It is not associated with the Utah state courts. To learn more about the project, check out our about page.

Downloads: You can download both the original form (last checked 2023-03) and the machine-processed form with normalized data fields.

About This Form:

Sourced from legacy.utcourts.gov (2023-03)
Page(s): 4
Fields(s): 114
Average fields per page: 28
Reading Level: Grade 8
LIST Grouping(s): GO-00-00-00-00.

Use our Rate My PDF tool to learn more. Go beyond the above insights and learn more about this or any pdf form at RateMyPDF.com, includes: counts of difficult words used, passive voice decetion, and suggestions for how to make the form more usable.

Identified Data Fields:

We have done our best to automaticly identify and name form fields according to our naming conventions. When possible, we've used names tied to our question library. See e.g., user1_name. If we think we've found a match to a question in our library, it is highlighted in green. Novel names are auto generated. So, you will probably need to edit some of them if you're trying to stick to the convention.

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The Legal Innovation & Technology Lab's Form Explorer Beta @ Suffolk Law School Last updated 2023-04-02

Petition for Judicial Review of Final Agency Action

About This Form:

Identified Data Fields:

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The Legal Innovation & Technology Lab's Form Explorer ^Beta @ Suffolk Law School Last updated 2023-04-02