Hardship Affidavit printable pdf download

HARDSHIP AFFIDAVIT

Jurors will only be excused if serving will cause an undue or extreme physical or financial

hardship. Such a hardship may be present if the juror has a mental or physical condition which

causes the juror to be incapable of performing jury service, or if the juror would: (a) be required to

abandon a person under such juror’s personal care of supervision due to the impossibility of

obtaining an appropriate substitute caregiver during the period of participation in the jury pool or on

the jury; (b) incur costs that would have a substantial adverse impact on the payment of the juror’s

necessary daily living expenses or those for whom such juror provides the principal means of

support; (c) suffer physical hardship that would result in illness or disease; or (d) be deprived of

compensation due to the fact the prospective juror works out of state and the out-of-state employer is

unwilling to compensate the juror, or that the prospective juror is employed by an employer who is

not required to compensate jurors and declines to do so voluntarily. An undue or extreme physical or

financial hardship does not exist solely based on the fact that a juror will be required to be absent

from the juror’s place of employment. If you wish to assert such a hardship, explain the nature of the

hardship and enclose an affidavit, income and expense statement, medical statement from a licensed

physician, proof of dependency or guardianship, or any other documentation which may be relevant

to your request. Failure to provide satisfactory documentation may result in the denial of your

request.

I, after being duly sworn, make oath that I believe a hardship exists where I should be excused from

jury service. My hardship is:___________________________________________

______________________________________________________________________________

Further affiant saith not.

___________________________________

____________________________________

Affiant’s printed name

Affiant’s Signature

___________________________________

Affiant’s phone number

Sworn to and subscribed before me this _____ day of ___________________, 20______.

____________________________________

Clerk/D.C

Hardship Affidavit