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Medical Affidavit Form - Clayton County Judicial Circuit

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CLAYTON COUNTY JUDICIAL CIRCUIT

MEDICAL AFFIDAVIT

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

Juror Name____________________________________ Juror #______________ Jury Service Date__________

Personally appeared before me, the undersigned witness, ___________________________________ who, under oath states as

follows:

(Physician’s Name)

PHYSICIAN: PLEASE COMPLETE ONLY ONE SECTION (NOT BOTH)

PERMANENTLY DISABLED

TEMPORARILY DISABLED

Patient, ____________________________________

Patient, ___________________________________

currently

being

treated

for

is currently being treated by me for

____________________________________________.

__________________________________________.

medical

opinion,

said

patient

The expected recover time is ______________

is permanently disabled and should not be

Days

Weeks or

Months.

considered for jury service, now or in the

(Indefinite time is not acceptable.)

future.

The patient could be considered for jury

service after the time specified.

(Juror will be

permanently

deferred.)

(Juror will be

temporarily

deferred for the

length of time specified.)

_______________________________________________

_____________________________________________

PHYSICIAN’S SIGNATURE

(REQUIRED)

PHYSICIAN’S PHONE NUMBER

Sworn to and subscribed before me this _________ day of _____________________________, 20________.

___________________________________________________

__________________________________________________

SIGNATURE OF A WITNESS

(REQUIRED)

TITLE OF WITNESS

(Someone who works in the physician’s

office ; i.e., RN, RECEPTIONIST, ETC.)

I hereby swear or affirm that the above information provided by my physician is true and correct. I also

acknowledge that the Office of the Clerk of Superior Court may contact my physician’s office to verify the

information given.

__________________________________________________

_________________________________________________

(REQUIRED)

JUROR’S SIGNATURE

JUROR’S PHONE NUMBER

In order for this form to be considered for a permanent or temporary deferment, either the

Permanently Disabled section or the Temporarily Disabled section must be filled out completely

and ALL 3 signatures must be included.

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

completed form may be faxed to the number 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

Or faxed to: 770-477-4519

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Medical Affidavit Form - Clayton County Judicial Circuit

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