Checklist For Affidavit And Summons Page 4
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1
2
3
4
5My Name
Address
Lehi City Justice Court
City, State, Zip
154 North Center S t r e e t
Phone
Lehi, UT 84043
Email
8 0 1 - 7 6 8 - 7 1 6 0
Plaintiff
[ ]
I am the
Attorney for the Plaintiff and my Utah Bar number is
[ ]
IN THE LEHI JUSTICE COURT
FOURTH JUDICIAL DISTRICT, UTAH COUNTY
154 NORTH CENTER STREET, LEHI, UTAH 84043
AFFIDAVIT AND SUMMONS
Plain ff
Vs.
Case Number
Defendant
Pual C. Farr
JUDGE
AND
Defendant
I swear that the following is true: (1)
for the claim described is paragraph (2).
Defendant‐owes me $
plus the court fling fee of
$
plus an es mated service fee of
$
for a total of
$
plus prejudgment, if qualified for prejudgment interest.
(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.
I have not included any non‐public information in this document
Date: __________________________________________________ Sign Here
Printed Name of Plain ff or Plain ff'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
Jus ce Court Clerk
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