Jury Duty Excuse Form

This form is used to request for an excuse for medical reasons or vacations.

If you need to be excused from jury service for other reasons, you need to send another request form within 7 days of this hearing.

Please be aware that supporting documents like doctor's statement are needed to be attached in this form.

Type of excuse

Court Name

Court Adddress/Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Description of your request

Reason for Excuse

Upload supporting documents here

Recommended file types: .doc, .docx, .pdf, .jpg, .png, xls, xlsx

Juror's Name

First NameLast Name

Juror's Number

Phone Number

Format: (000) 000-0000.

Email

example@example.com

Signature

Date Signed

Date