Counter Affidavit And Summons (Small Claims) Form (Page 2 of 4) in pdf

Counter Affidavit And Summons (Small Claims) Form Page 2

(2)

The events happened on ______________________

. My claim is based on

(date)

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)

[ ]

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

(5)

[ ]

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.

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

Sign here ►

Date:

Printed Name. Defendant or Defendant’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.

Sign here ►

Date:

Notary or Court Clerk

Notary Seal

Counter Affidavit and Summons (Small Claims)

Approved Board of Justice Court Judges September 22, 2010

Page 2 of 4

Revisions Approved by Supreme Court July 18, 2016

Counter Affidavit And Summons (Small Claims) Form Page 2