Fillable Affidavit For Excusal Or Deferral Form printable pdf download

IN THE SUPERIOR AND STATE COURT OF OCONEE COUNTY,

STATE OF GEORGIA

AFFIDAVIT FOR EXCUSAL OR DEFERRAL

Personally appeared before the undersigned officer duly authorized to administer oaths, came

__________________________________, who on oath says, I have been summoned for jury service to report

on________________, and hereby request to be excused from this summons by the Judge or deferred by the

Clerk of Court from jury service due to the following:

I am a full-time student at a college, university, vocational school, or other post secondary school

who is enrolled and taking classes or exams on the dates indicated in my jury summons. Juror shall

provide proof of enrollment and school calendar.

I am the primary care giver having active care and custody of a child six years of age or younger and

have no reasonably available alternative child care.

I am the primary, unpaid care giver for a person over six years of age with such physical or cognitive

limitations that he or she is unable to care for him/herself and cannot be left unattended and there is not

reasonably available alternative care. Juror shall provide a statement of a physician or other medical

provider supporting the affidavit.

I am a primary teacher of a Home School Program. Juror shall provide proof of home study program

and school calendar.

I am a Legislator and will be in attendance in the Legislature.

I am an active member of the US Armed Forces or spouse of such service member on ordered

military duty which requires me to be at least 50 miles from home. Juror shall present copy of valid

military identification.

I have a temporary medical condition that would prevent attendance on the dates for which presence

is required for service. Juror shall provide a statement from a physician stating such fact.

I will be engaged during this term of jury duty in work necessary to the public health, safety or good

order or can show other good cause. Juror shall provide a statement substantiating the facts (Specify):

___________________________________________________________________________________

_________________________________________________________________________

______________________________________________________________________________

Other (Specify):

___________________________________________________________________________________

_________________________________________________________________________

______________________________________________________________________________

This __________ day of ___________________________, 20 ____.

___________________________________________________

Juror

Phone #

Sworn to and subscribed before me this _______ day of _________, 20____

_______________________________

Notary Public/Clerk of Superior Court (Seal)

Notary term expires_______________

TWO SIDED DOCUMENT

Affidavit For Excusal Or Deferral Form