Form (404) 371-2022 - Medical Affidavit - Affidavit For Persons 70 Years Of Age Or Older

ADVERTISEMENT

STATE OF GEORGIA
S
C
S
M
J
C
UPERIOR
OURT OF THE
TONE
OUNTAIN
UDICIAL
IRCUIT
JURY DIVISION
ROOM 100
556 NORTH McDONOUGH STREET
DECATUR, GEORGIA 30030
(404) 371-2022
D
KALB COUNTY
E
IF YOU ARE SEEKING A MEDICAL OR AGE EXEMPTION, PLEASE RETURN THE APPROPRIATE AFFIDAVIT BELOW.
THE AFFIDAVIT MUST BE NOTARIZED.
Participant Number: _____________________
Date of Service: ___________________________
MEDICAL AFFIDAVIT
Personally appeared before me, the undersigned officer duly authorized to administer oaths, _________________________________
Physician’s Name
who under oath states as follows:
(1)
Patient, _________________________________ is currently being treated by me for ______________________________________
__________________________________________________________________________________________________________.
In my medical opinion, said patient is permanently disabled and should not be considered for jury service, now or in the future.
(2)
Patient, ________________________________ is currently being treated by me for _______________________________________
__________________________________________________________________________________________________________.
The expected recovery time is ___________________(days/weeks, etc.) and should be considered for jury service at that time.
_____________________________________
Physician’s Signature
PRINT NAME OF PHYSICIAN _______________________________________
PHYSICIAN’S PHONE #
_______________________________________
=============================================================================================
Participant Number: _______________________
Date of Service: __________________________
AFFIDAVIT FOR PERSONS 70 YEARS OF AGE OR OLDER
I hereby request that my name be removed from the jury list, in accordance with section 15-12-1(b) of the Official Code of Georgia,
relating to exemption from jury service for persons 70 years of age or older. In compliance with the law, I submit the following
Affidavit:
AFFIDAVIT
Comes now before the undersigned officer duly authorized to administer oaths, the Deponent who after being sworn states and affirms
that his/her date of birth is ____________________ and has attained the age of ______________, and wishes his/her name to be
removed from the jury list and jury pool.
___________________________________________________
_________________________________________________
Signature
Print Name
___________________________________________________
_________________________________________________
Address
City
Zip Code
__________________________________________________ _________________________________________________
Home/Mobile Telephone Number
Work Telephone Number
Sworn to and subscribed before me this ______ day of ___________________, 20_____.
_______________________________________________________
NOTARY PUBLIC, _______________________ County, Georgia.
My Commission expires: _________________________________

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Ccl 357 - Health Status Form For Persons 14 Years Of Age Or Older Working Or Volunteering In School Age Programs Ccl 357 - Health Status Form For Persons 14 Years Of Age Or Older Working Or Volunteering In School Age Programs Legal
Pbctc Form 49 - Application For Business Tax Exemption For Disabled Persons, Widows With Minor Dependents Or Persons 65 Years Of Age Or Older - Palm Beach County Tax Collector Pbctc Form 49 - Application For Business Tax Exemption For Disabled Persons, Widows With Minor Dependents Or Persons 65 Years Of Age Or Older - Palm Beach County Tax Collector Legal
Application Limitation Of Increase In Value For Single-family Dwellings Occupied By Low-income Owners: 65-years-of-age Or Older; Or Disabled - State Of New Mexico Application Limitation Of Increase In Value For Single-family Dwellings Occupied By Low-income Owners: 65-years-of-age Or Older; Or Disabled - State Of New Mexico Financial
Application-limitation On Increase In Value For Single Family Dwellings Occupied By Low Income Owners 65 Years Of Age Or Older Or Disabled - State Of New Mexico - 2018 Application-limitation On Increase In Value For Single Family Dwellings Occupied By Low Income Owners 65 Years Of Age Or Older Or Disabled - State Of New Mexico - 2018 Financial
Application Form For Enhanced Star (school Tax Relief) Property Tax Reduction For Senior Citizens, 65 Years Of Age Or Older - State Of New York Application Form For Enhanced Star (school Tax Relief) Property Tax Reduction For Senior Citizens, 65 Years Of Age Or Older - State Of New York Financial
Application-limitation On Increase In Value For Single Family Dwellings Occupied By Low Income Owners 65 Years Of Age Or Older Or Disabled - 2011 Application-limitation On Increase In Value For Single Family Dwellings Occupied By Low Income Owners 65 Years Of Age Or Older Or Disabled - 2011 Financial
Application-limitation On Increase In Value For Single Family Dwellings Occupied By Low Income Owners 65 Years Of Age Or Older Or Disabled - 2011 Application-limitation On Increase In Value For Single Family Dwellings Occupied By Low Income Owners 65 Years Of Age Or Older Or Disabled - 2011 Financial
Trip Or Activity Liability Release Form (18 Years Of Age Or Older) Trip Or Activity Liability Release Form (18 Years Of Age Or Older) Legal
Patient Registration Form - 18 Years Of Age Or Older (no Dependants) Patient Registration Form - 18 Years Of Age Or Older (no Dependants) Medical
Adult Abroad General Passport Application For Canadians 16 Years Of Age Or Over Applying Outside Of Canada And From The Usa Adult Abroad General Passport Application For Canadians 16 Years Of Age Or Over Applying Outside Of Canada And From The Usa Life

Related Categories

Parent category: Legal
Download
Go