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

Affidavit And Summons (Small Claims) Form Page 2

(2)

The events happened on _________________________

. My claim is

(date)

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 ►

Date

Typed or 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.

Sign here ►

Date

Typed or printed name (Court Clerk or Notary Public)

Notary Seal

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

Affidavit And Summons (Small Claims) Form Page 2