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

In the Justice Court of Utah 

__________ Judicial District ________________ County 

Court Address ______________________________________________________ 

_____________________________________ 
Plaintiff 

Affidavit and Summons  
(Small Claims) 

v. 

And 

_____________________________________ 
Defendant 

_____________________________________ 
Defendant 

 

I swear that the following is true. 

_______________________________ 
Case Number 

_______________________________ 
Judge 

(1) Defendant owes me 

$ 

for the claim described in paragraph (2). 

plus the filing fee of  $ 

plus an estimated service fee of  $ 

plus estimated attorney fees of  $ 

for a total of:  $ 

 

 

plus prejudgment interest, if qualified for prejudgment interest. 

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

Affidavit and Summons (Small Claims) 

Approved Board of Justice Court Judges September 22, 2010 
Revised May 9, 2017 

Page 1 of 4 

 

 

ity, State, Zip 

hone 

mail 
 
I am the 
 

 

  A

  C

  P

  E

 
Name 

ddress 

(2) 

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

(3) 

[  ] 
[  ] 

Defendant resides within the jurisdiction of the court. 
The events happened within the jurisdiction of the court. 

(4) 

[  ] 

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

(5) 

[  ] 

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

(6) 

[  ] 

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

Sign here ► 

 

 

Typed or Printed Name 

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. 

Typed or printed name (Court Clerk or Notary Public) 

Sign here ► 

Notary Seal 

 

 

 

Affidavit and Summons (Small Claims) 

Approved Board of Justice Court Judges September 22, 2010 
Revised May 9, 2017 

Page 2 of 4 

 

 

 

             

 
Date 

 
Date 

 

 

Summons 

 

 

 

 

 

 

 

 

 

To: 

 

 

 

 

 

 

 

 

Para: 

Defendant Name and Address 

      Nombre y dirección del Demandado  

Defendant Name and Address 

       Nombre y dirección del Demandado  

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) 

 

 

Judge (Juez) 

 

Notice to the Defendant 

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. 

Affidavit and Summons (Small Claims) 

Approved Board of Justice Court Judges September 22, 2010 
Revised May 9, 2017 

Page 3 of 4 

Time (Hora) 

: 

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

[  ] p.m. 

 

 

 

Date: 

 

 

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 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 

 

 

Affidavit and Summons (Small Claims) 

Approved Board of Justice Court Judges September 22, 2010 
Revised May 9, 2017 

Page 4 of 4