Jury Duty Deferral Request
Submit your request to postpone your assigned jury duty. Please complete all sections accurately.
Full Name
*
First Name
Last Name
Best Contact Information
*
Email
Phone
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Jury Summons Number
*
Summons Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assigned Jury Service Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Requesting a Deferral
*
Medical or health reasons
Travel or prior commitment
Work or school conflict
Family or dependent care
Other (please specify below)
Preferred New Service Date or Availability Window
*
Supporting Explanation or Details
*
Upload Supporting Document (if any)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Signature
*
Submit Request
Submit Request
Should be Empty: