ity, State, Zip 

 
Name 

ddress 

hone 

mail 

  A

  C

  P

  E

I am the 
 

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

In the Justice Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

_____________________________________ 
Plaintiff 

Counter Affidavit and Summons 
(Small Claims) 

v. 

And 

_____________________________________ 
Defendant 

_____________________________________ 
Defendant 

I swear that the following is true. 

1. Plaintiff owes me 

plus the filing fee of 
plus estimated 
attorney fees of 

for a total of: 

$ 

$ 

 

$ 

 

 

_______________________________ 
Case Number 

_______________________________ 
Judge 

for the claim described in paragraph (2). 

 
(Attach statute or contract showing you 
are authorized to claim attorney fees.) 

plus prejudgment interest, if qualified for prejudgment interest. 

Counter Affidavit and Summons (Small Claims) 

Approved Board of Justice Court Judges September 22, 2010 
Revised January 16, 2020 

Page 1 of 4 

 

2. 

The events happened on ______________________ (date). My claim is based on 
the following facts. 

3. 

[  ] 

I am not suing a government entity. I am not suing a government 
employee for the employee’s on-the-job conduct. 

4. 

5. 

[  ] 

[  ] 

I am not suing on a claim that has been assigned to me. 

I understand that I may be barred from later bringing any claims arising 
out of the event or transaction if the claims are not described in this 
affidavit. 

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

Date: 

 

Signature ► 

Printed Name of Defendant or Defendant’s Agent 

 

n 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 

 

 

 

Counter Affidavit and Summons (Small Claims) 

Approved Board of Justice Court Judges September 22, 2010 
Revised January 16, 2020 

Page 2 of 4 

 

           

 

  O

Time (Hora) 

: 

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

[  ] p.m. 

To: 

 

 

 

 

 

 

 

 

 

Para: 

Plaintiff Name and Address   

      Nombre y dirección del Demandante  

Summons 

 

 

 

 

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. 

The original trial date  

[  ]  has not changed 

(La fecha original para juicio) 

no ha sido cambiada 

Date (Fecha) 

Room (Sala) 

 

 

 

[  ]  has been changed to: 
ha sido cambiada para: 
 

Judge (Juez) 

 

Notice to the Plaintiff 

A counterclaim has been filed against you. This imposes upon you certain rights and 
responsibilities. You can find small claims information and instructions at 
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 contrademanda ha sido presentado contra usted. Esto le impone a usted ciertos 
derechos y obligaciones.  Usted puede encontrar información e instrucciones sobre 
reclamos menores en www.utcourts.gov/howto/smallclaims/. 

La página de la internet del tribunal Cómo encontrar ayuda legal 
(www.utcourts.gov/howto/legalassist/index-sp.html/) tiene información sobre algunas 
maneras de encontrar ayuda legal, incluyendo el Centro de Ayuda de los Tribunales 
de Utah, abogados que ofrecen descuentos u ofrecen ayuda legal limitada, y 
talleres legales gratuitos. 

Counter Affidavit and Summons (Small Claims) 

Approved Board of Justice Court Judges September 22, 2010 
Revised January 16, 2020 

Page 3 of 4 

 

 

 

 

 

Attendance. You must attend. If you do not attend, you might be held in contempt of 
court and 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, se lo 
podría encontrar en desacato de las órdenes del juez y la reparación solicitada 
podría ser otorgada. Usted tiene el derecho de que lo represente 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, the court will provide an 
interpreter. Contact court staff immediately to ask for an interpreter. 

Interpretación. Si usted no habla ni entiende el Inglés el tribunal le proveeré un 
intérprete. Contacte a un empleado del tribunal inmediatamente para pedir un 
intérprete. 

ADA Accommodation. If you need an accommodation, including an ASL interpreter, 
contact court staff immediately to ask for an accommodation.. 

Adaptación o Arreglo en Caso de Discapacidad. Si usted requiere una 
adaptación o arreglo, que incluye un intérprete de la lengua de signos americana, 
contacte a un empleado del tribunal inmediatamente para pedir una adaptación.     

Date 

 

Signature ► 

Court Clerk 

I certify that I mailed a copy of this document to the following people. 

Certificate of Service 

Person’s Name 

Address 

Date Sent 

 

 

 

 

 

 

Date 

 

Signature ► 

Court Clerk 

Counter Affidavit and Summons (Small Claims) 

Approved Board of Justice Court Judges September 22, 2010 
Revised January 16, 2020 

Page 4 of 4