Form 12140 "Certification in Support of Request for Excuse From Jury Service: Personal Obligation to Provide Care for Minor Child(Ren)" - New Jersey

What Is Form 12140?

This is a legal form that was released by the New Jersey Superior Court - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2020;
  • The latest edition provided by the New Jersey Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 12140 by clicking the link below or browse more documents and templates provided by the New Jersey Superior Court.

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Download Form 12140 "Certification in Support of Request for Excuse From Jury Service: Personal Obligation to Provide Care for Minor Child(Ren)" - New Jersey

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Superior Court of New Jersey
Certification in Support of Request for Excuse from Jury Service:
Personal Obligation to Provide Care for Minor Child(ren)
Name
County
Candidate ID
Phone
or
Email
Summons Date
I,
, of full age, hereby certifies as follows:
This certification is made by me in support of my request to be excused from jury service on
, in
County.
A person may be excused from jury service for particular reasons, including:
c. Jury service will impose a severe hardship due to circumstances which are not likely
to change within the following year. Severe hardship includes the following
circumstances:
3. The prospective juror has a personal obligation to care for another, including…a
minor child, who requires the prospective juror’s personal care and attention, and no
alternative care is available without severe financial hardship on the prospective juror
or the person requiring care. N.J.S.A. § 2B:20-10(c)(3).
I am personally obligated to care for the following minor child/ren (attach additional sheets as
necessary):
Child’s Name
Child’s Age
1.
2.
3.
4.
I understand that I may be required to provide further information and/or financial documentation for
review by the court in support of this request.
I hereby certify and say that the foregoing statements made by me are true. I am aware that if any of
the foregoing statements made by me are willfully false, I am subject to punishment.
Date
Signature
Print Name
Revised: 01/2020, CN 12140
Print
Clear
Superior Court of New Jersey
Certification in Support of Request for Excuse from Jury Service:
Personal Obligation to Provide Care for Minor Child(ren)
Name
County
Candidate ID
Phone
or
Email
Summons Date
I,
, of full age, hereby certifies as follows:
This certification is made by me in support of my request to be excused from jury service on
, in
County.
A person may be excused from jury service for particular reasons, including:
c. Jury service will impose a severe hardship due to circumstances which are not likely
to change within the following year. Severe hardship includes the following
circumstances:
3. The prospective juror has a personal obligation to care for another, including…a
minor child, who requires the prospective juror’s personal care and attention, and no
alternative care is available without severe financial hardship on the prospective juror
or the person requiring care. N.J.S.A. § 2B:20-10(c)(3).
I am personally obligated to care for the following minor child/ren (attach additional sheets as
necessary):
Child’s Name
Child’s Age
1.
2.
3.
4.
I understand that I may be required to provide further information and/or financial documentation for
review by the court in support of this request.
I hereby certify and say that the foregoing statements made by me are true. I am aware that if any of
the foregoing statements made by me are willfully false, I am subject to punishment.
Date
Signature
Print Name
Revised: 01/2020, CN 12140