JUSTICE/DISTRICT COURT OF ____________________ COUNTY/CITY _____________ JUDICIAL DISTRICT ADDRESS: _______________________________________________ ______________________________________________, Plaintiff Name ______________________________________________________ Street Address ______________________________________________________ City, State, Zip SMALL CLAIMS INTERPLEADER AFFIDAVIT AND SUMMONS (FORM C) VS. ____________________________________________, Defendant Name ______________________________________________________ Street Address ______________________________________________________ City, State, Zip Case No. _____________________ AND ____________________________________________, Defendant Name ______________________________________________________ Street Address ______________________________________________________ City, State, Zip AFFIDAVIT Plaintiff swears that the following is true: (1) Plaintiff is holding $ ___________ for the following reason: (2) Defendants say or may say that they should have the money. (3) Both defendants reside or the claim arose within the jurisdiction of this court. (4) Plaintiff has [ ] paid the money into the court OR [ ] will pay the money as directed by the court. Plaintiff’s or Agent’s Signature American LegalNet, Inc. www.FormsWorkflow.com Subscribed and sworn to before me on ________________________. Clerk’s or Notary’s Signature SUMMONS THE STATE OF UTAH TO THE DEFENDANTS: You are summoned to appear at trial to answer the above claim. The trial will be held at the court address shown above. Date of trial Time of trial If you do not appear, judgment may be entered determining your claim to the above-described money. You may also be ordered to pay the costs of the action. Date Clerk’s Signature NOTICE TO THE DEFENDANT: A small claims case has been filed against you. This imposes upon you certain rights and responsibilities. If you need information, you may obtain a small claims information and instruction manual from the clerk of the court for a fee or you may obtain it for free at: www.utcourts.gov. ADA NOTICE: If you need special accommodations (including communication aids and services) during this proceeding should call (name)__________________ at (phone)_________, at least three days before the proceeding. 16 American LegalNet, Inc. www.FormsWorkflow.com