Small Claims Counter Affidavit & Summons Form - Salt Lake City Justice Court

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333 SOUTH 200 EAST, PO BOX 145499, SALT LAKE CITY, UT 84111-5499
Phone: (801)535-6301 / Fax: (801)535-6302 /
Name_____________________________________________, Plaintiff )
Street Address_______________________________________________ )
City, State, ZIP______________________________________________ )
Name___________________________________________, Defendant )
Street Address_______________________________________________ )
Case No._________________________
City, State, ZIP______________________________________________ )
I am the
Attorney for Defendant and my Utah Bar number is _________. I swear that the following is true:
(1) Plaintiff owes me
$______________ for the claim described in (2)
plus the filing fee of
plus estimated attorney fees 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. ______________________________
I am not suing a government entity. I am not suing a government employee for the employee’s on-the-job conduct
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 have not included any non-public information on this document.
Sign here ►
Printed Name►___________________________________________
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.
Court Clerk or Notary Sign Here ►
(Notary Seal)
THE STATE OF UTAH TO THE PLAINTIFF(S): You are summoned to appear at a trial to answer the above claim.
If you fail to appear, judgment may be entered against you for the amount claimed.
The original trial date remains unchanged and is on:
The original trial date has been changed to:
Trial Date: ________________________________ Time: 5:30pm
Place: 333 S 200 E, Salt Lake City, UT 84111
Certificate of Service
I certify that I mailed a copy of this Small Claims Counter Affidavit and Summons to the following people.
Person Name:
Date Sent:
Court Clerk Signature ►
Notice to the Plaintiff: A small claims case has been filed against you. This imposes upon you certain right and responsibilities. You may obtain small
claims information and instructions at
Disability Accommodations: If you need accommodation of a disability, contact a judicial service assistant at least 3 days before the hearing.


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