Fillable Care-Giver Affidavit Form - Clayton County Judicial Circuit printable pdf download

Care-Giver Affidavit Form - Clayton County Judicial Circuit

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CLAYTON COUNTY JUDICIAL CIRCUIT

CARE-GIVER AFFIDAVIT

NOTE: THIS FORM MUST BE COMPLETED & CONTAIN ALL SIGNATURES IN ORDER TO BE CONSIDERED.

Juror Name____________________________________ Juror #______________ Jury Service Date__________

I hereby affirm that I am the primary, UNPAID care-giver for ______________________________________ ,

a person over the age of six years; and I am responsible for the care of said person with such physical

or cognitive limitations that he/she is unable to care for himself/herself and cannot be left unattended.

I further affirm that I have no reasonable available alternative to provide for the care and therefore I

am requesting to be excused from jury duty in accordance with OCGA §15-12-1.1(a)(5). I acknowledge

and understand that this affidavit is valid only for the current state-wide master jury list, which is

revised every year. In addition, my signature affirms the information provided below by the physician.

___________________________________________

_____________________

__________________________

JUROR’S SIGNATURE (Required)

Today’s Date

Juror’s Phone Number

Witnessed this ________ day of ____________________, 20_______.

_____________________________________________________

NOTARY PUBLIC OR DEPUTY COURT CLERK (Required)

(If you are mailing or faxing in this form, your signature must be notarized.)

TO BE COMPLETED BY PHYSICIAN (REQUIRED)

Personally appeared before me, the undersigned witness, ____________________________________,

(Physician’s Name)

who, under oath states as follows:

Patient, _______________________________________________, is currently being treated by me. In my

medical opinion, said patient has such physical or cognitive limitations that he/she is unable to care

for himself/herself and cannot be left unattended.

__________________________________________

______________________________________

PHYSICIAN’S SIGNATURE (Required)

Physician’s Phone Number

Sworn and subscribed before me this _______ day of ________________________, 20________.

___________________________________________

_______________________________________

WITNESS’ SIGNATURE (Required)

WITNESS’ TITLE

(Someone who works in the

physician’s office; i.e., RN, Receptionist, etc.)

In order for this form to be considered, it must be filled out completely and ALL 4 signatures must be included.

The completed form may be delivered/mailed to the address listed below. If you need to expedite your request, you may

fax the completed form to the fax number listed below; however, the ORIGINAL FORM MUST ALSO BE SUBMITTED to our

office.

Jacquline D. Wills, Jury Division

9151 Tara Blvd., Suite 1JA01

Jonesboro, GA 30236-4912

Fax Number: 770-477-4519

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Care-Giver Affidavit Form - Clayton County Judicial Circuit

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