Request for Excusal/Deferral

County Summoned for Jury Duty*:

Candidate ID (leading zeros not required)*:

First Name*:

Last Name*:

Address*:

City*:

State*:

ZipCode*:

Email:

Click here to receive an email copy of this form:

Phone*:

Phone Type*:

Mobile Land line

Please select and complete one of the options below if requesting to be excused or temporarily deferred from jury service.

Illness or Injury - Such as chronic illness, physical injury or disability.

Please Explain:

Must include a physician's note with your request.
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I am no longer a resident of County.

Please provide residential address:

Undue Hardship/Extreme Inconvenience - Due to family medical, military service, financial hardship, occupation, or extreme inconvenience. The court will determine whether to excuse or defer you to serve at a later date based on the information provided.

Please Explain:

Request for a temporary deferral from jury service: Examples may include a planned vacation, business trip, student, or any other situation of where you may currently be unavailable. Please include dates or date ranges of future unavailability.

Please Explain:

I declare that my responses to the questions on this form are true and correct to the best of my knowledge. Signature of Prospective Juror* To sign eletronically: /s/