Fillable JURY EXEMPTION FORM ARE YOU REQUESTING EXEMPTION FROM (Emanuel County Board of Commissioners)

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JURY EXEMPTION FORM ARE YOU REQUESTING EXEMPTION FROM (Emanuel County Board of Commissioners)

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BROWSE EMANUEL COUNTY BOARD OF COMMISSIONERS (GA) FORMS

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JURY EXEMPTION FORM
ARE YOU REQUESTING EXEMPTION FROM JURY DUTY?
_____ YES PLEASE COMPLETE THIS ENTIRE EXEMPTION PAGE.
_____ NO PLEASE COMPLETE REVERSE SIDE / INFORMATION FORM.
***If you request an exemption and qualify as specified below, you will not be contacted by the
Clerk’s Office. You will be notified ONLY if there is an issue with your request for exemption.
JUROR
NAME______________________________________________DOB___/___/___AGE______
JUROR
ADDRESS_______________________________CITY________________STATE___ZIP_______
JUROR CONTACT PHONE#__________________________(FOR COURT USE ONLY)
I HEREBY AFFIRM THAT I AM:
___70(+) YEARS OF AGE AND I WISH TO BE REMOVED FROM JURY DUTY
___LIVES OUT OF COUNTY
***I RESIDE IN ______________ COUNTY ______________ STATE
___MEDICALLY UNABLE TO SERVE (MUST PROVIDE DOCUMENTATION FROM HEALTHCARE PROVIDER)
***IS YOUR CONDITION: __ TEMPORARY __ PERMANENT (CLERK’S FAX: 478-237-1220)
___PRIMARY CAREGIVER
_______ CHILDREN UNDER THE AGE OF SIX AND NOT ENROLLED IN SCHOOL
_______ ELDERLY
___FULL TIME TEACHER **** NOT A VALID EXEMPTION FOR JULY JURY SERVICE
SCHOOL OF EMPLOYMENT: ________________________________________
___FULL TIME STUDENT – SCHOOL_____________________
___ FELON (ONLY USE THIS IF YOUR RIGHTS WERE NOT RESTORED)
DATE/LOCATION OF CONVICTION: _____________________________________________________
___NON-CITIZEN OF US
COUNTRY OF CITIZENSHIP: ___________________________________________
___ ACTIVE MILITARY
___I AM UNABLE TO SERVE FOR THE FOLLOWING REASON: (***If you complete this area, you must
contact Denise Hobbs at the Clerk’s Office 478-237-8911 X118 to discuss reason for exemption.)
__________________________________________________________________________________________
__________________________________________________________________________________________
________________________________ ______________
SIGNATURE OF JUROR DATE
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JURY EXEMPTION FORM ARE YOU REQUESTING EXEMPTION FROM (Emanuel County Board of Commissioners)

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Completed 17 July 2020

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