Full Name:
Excuse Request Form
You must complete and submit your online questionnaire before submitting this form.
Complete this form only if you are requesting to be excused from jury service for one or more of the reasons listed
below. Please complete the section(s) that applies to your situation. After completing this form, either e-mail it to
jury@cacd.uscourts.gov or fax it to (213) 894-3751, Attn: Jury Department.
1. If you are requesting to be excused because of business, employment, or financial hardship, you must answer
questions 1(a) through 1(i), below. If you do not answer all the questions in full, your request will likely be denied.
If you do not submit this form and later request to be excused on the basis of financial hardship, your request will
likely be denied unless new circumstances have arisen in the interim.
(a) employer's name:
(d) number of days paid for jury service:
(e) number of people living in your household (provide ages):
(f) number of people in your household who are employed:
(g) total monthly income from all sources:
(h) total monthly expenses:
Juror Participation Number:
(b) occupation or job title:
(c) number of employees who work for the company and number in your department or unit:
(i) additional facts to further explain your situation:
2. If you are requesting to be excused because you live 80 miles or more one way from the court and staying at a
hotel each night at the court's expense would not relieve your hardship, you must provide a detailed explanation
of your hardship (include one-way mileage and commute time).
J-013 (08/19)
EXCUSE REQUEST FORM - ONLINE
