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Jury Form

Leave This Blank:

First Name:*

Last Name:*

Date to appear:*

Jury Number:*

Please Check the following Exemption you are Claiming:*

	You are over 70 years old
	You have legal custody of a child or children younger than 12 years of age and service on the jury would require leaving the children without adequate supervision
	you are a student at a public or private high school
	you are enrolled and attend college
	You are an officer or employee of the senate, the house of representatives or any department, commission, board, office or agency in the legislative brand of state government

	you are the primary caretaker of a person who is an invalid unable to care for himself or herself. (this exemption does not apply to health care workers.)
	You are a member of the United State millitary forces serving on active duty and deployed to a location away from the person's home station and out the person's county of residence.
	I am claiming an disqualification
	Covid Screening

Please check the following Disqualification you are claiming:*

	Be at lease 18 years old
	be a citizen of this state and a resident of the county in which you are to serve as a juror
	be qualified under the Constitution and laws to vote in the county in which you are to serve as a juror ( Note: you DO NOT have to be registered to vote to be qualified to serve as a juror)
	be of sound mind and good moral character
	be able to read and write

	not have served as a juror for six days during the preceding three months in the county court or during the preceding six months in the district court
	not have been convicted of midemeanor theft or any felony
	not under indictment or other legal accusation of a misdemenor theft, felony theft or any other felony charge
	I am claiming an Exemption

I DO HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT I AM:*

EXEMPT because of the reason checked above

DISQUALIFIED because of the reason circled above

Date:*

Email address?*

* indicates required fields.

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