Clerks of Court, in their role as Jury Administrators, receive names and addresses of prospective jurors from
the State of Florida, Division of Drivers Licenses twice annually. From the data we receive, a random list is
drawn every time we need jurors for both civil and criminal trial weeks. Please fill out this form and send it
back to us only if you are choosing to be withdrawn from future jury service
. Remember, you may be
permanently excused from that pool if you are seventy or more years of age, but please know it is your
choice alone. Many who have reached the age of seventy still wish to serve and are encouraged to
continue to serve as jurors. If you do, please know your Clerk and Judiciary will welcome you!
PERMANENT JUROR EXCUSAL FORM
REQUEST FOR EXCUSAL
Exemption (Optional Excuse)
Seventy (70) years of age or older and request permanent excusal
Please complete the following:
Your name as it appears on your Florida Driver’s license:
___________________________________________________________________________________
First Name Middle Name or Initial Last Name
Your address as it appears on your Florida Driver’s lic
ense:
___________________________________________________________________________________
Street or Post Office Address
City State ZiCodep
Your date of birth and a phone number where we can reach you should we need more information:
_________________________________________________________________________________
Date of Birth Phone Num
ber
Should you choos
e to print and mail this form: __________________________________________
Your
signature
If you are mailing this
request, please return it to:
TOM BEXLEY, CLERK OF CIRCUIT COURT & COMPTROLLER
FLAGLER COUNTY
JURY ADMINISTRATION
1769 E MOODY BLVD, BLDG #1
BUNNELL FL 32110
You may consider your request granted unless we notify you otherwise!
Your Florida Driver’s License Number:
___________________________________________________________________________________
Your Email Address (so we can send you confirmation of receipt of this form):
___________________________________________________________________________________
click to sign
signature
click to edit
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