"Affidavit for Exemption From Jury Duty for Physical or Mental Impairment" - Texas

"Affidavit for Exemption From Jury Duty for Physical or Mental Impairment" - Texas Download Pdf
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AFFIDAVIT FOR EXEMPTION FROM JURY DUTY
FOR PHYSICAL OR MENTAL IMPAIRMENT
Government Code Section 62.109 allows for a permanent or temporary exemption from jury service based upon a
physical or mental impairment.
The exemption may only be granted by court order once an affidavit and
physician’s statement is received from the prospective juror.
Please complete the affidavit and physician’s
statement and mail or fax them to Jury Services for submission to the Court. You will be notified if your request is
granted or denied.
**Please understand that once a judge makes a ruling; Jury Services cannot modify or change the decision.**
Govt. Code 62.109(b) A person requesting an exemption under this section must submit to the court an affidavit
stating the person’s name and address and the reason for and the duration of the requested exemption….
Applicant’s Name: ___________________________________________ Juror No.: _____________________
Applicant’s Full Address: ____________________________________________________________________
Date of Birth: _____________________ Daytime phone: ___________________________________________
Evening Phone: ____________________________ email: __________________________________________
Are you currently working?
YES
or
NO
If yes, please list occupation & employer: _______________________________________________________
(REQUIRED)
*Applicant requests exemption for the following, specific condition(s)
:
(Only listing “medical” is not sufficient, and will not be accepted)
__________________________________________________________________________________________
__________________________________________________________________________________________
Exemption requested: (Please check one)
PERMANENT
TEMPORARY
Applicant states: “I am aware that jury service is not necessarily physically difficult, however, as a direct
result of my physical or mental impairment, it is impossible or very difficult for me to serve on a jury.”
A physician’s statement
MUST
be attached to this affidavit. The name and address of the physician is:
Name:
_______________________________________________________________________
Address:
_______________________________________________________________________
PLEASE NOTE THE FOLLOWING
The affidavit must be completed in its entirety, with specific conditions(s) for requesting exemption listed, and
must be notarized. Once completed it may be FAXED to: 940-349-2231 OR mailed to JURY SERVICES,PO
BOX 2146, DENTON, TX 76202 along with the accompanying physician’s statement and completed juror
questionnaire. You may complete your juror questionnaire online at jury.dentoncounty.com.
*Incomplete affidavits will NOT be submitted to the court.*
STATE OF TEXAS
COUNTY OF DENTON
“I _______________________________________, on my oath state the above and foregoing statements are
within my knowledge true and correct.”
__________________________________________
Signature of Applicant or Applicant’s Designee
Subscribed and sworn before me the undersigned this _________ day of ______________________________,
20 ______.
___________________________________________
Notary Public or Deputy Clerk
ORDER
The above affidavit for exemption from jury duty was presented to the ___________ Court of Denton
County, Texas. The Court orders that the request for exemption should be
granted
denied .
If granted, the applicant will be exempt from jury duty in the justice, county and district courts of Denton
County, Texas for the period of time specified by the Physician’s Statement.
Signed this ____________ day of _______________________________________________, 20
___________________________________________
Presiding Judge
AFFIDAVIT FOR EXEMPTION FROM JURY DUTY
FOR PHYSICAL OR MENTAL IMPAIRMENT
Government Code Section 62.109 allows for a permanent or temporary exemption from jury service based upon a
physical or mental impairment.
The exemption may only be granted by court order once an affidavit and
physician’s statement is received from the prospective juror.
Please complete the affidavit and physician’s
statement and mail or fax them to Jury Services for submission to the Court. You will be notified if your request is
granted or denied.
**Please understand that once a judge makes a ruling; Jury Services cannot modify or change the decision.**
Govt. Code 62.109(b) A person requesting an exemption under this section must submit to the court an affidavit
stating the person’s name and address and the reason for and the duration of the requested exemption….
Applicant’s Name: ___________________________________________ Juror No.: _____________________
Applicant’s Full Address: ____________________________________________________________________
Date of Birth: _____________________ Daytime phone: ___________________________________________
Evening Phone: ____________________________ email: __________________________________________
Are you currently working?
YES
or
NO
If yes, please list occupation & employer: _______________________________________________________
(REQUIRED)
*Applicant requests exemption for the following, specific condition(s)
:
(Only listing “medical” is not sufficient, and will not be accepted)
__________________________________________________________________________________________
__________________________________________________________________________________________
Exemption requested: (Please check one)
PERMANENT
TEMPORARY
Applicant states: “I am aware that jury service is not necessarily physically difficult, however, as a direct
result of my physical or mental impairment, it is impossible or very difficult for me to serve on a jury.”
A physician’s statement
MUST
be attached to this affidavit. The name and address of the physician is:
Name:
_______________________________________________________________________
Address:
_______________________________________________________________________
PLEASE NOTE THE FOLLOWING
The affidavit must be completed in its entirety, with specific conditions(s) for requesting exemption listed, and
must be notarized. Once completed it may be FAXED to: 940-349-2231 OR mailed to JURY SERVICES,PO
BOX 2146, DENTON, TX 76202 along with the accompanying physician’s statement and completed juror
questionnaire. You may complete your juror questionnaire online at jury.dentoncounty.com.
*Incomplete affidavits will NOT be submitted to the court.*
STATE OF TEXAS
COUNTY OF DENTON
“I _______________________________________, on my oath state the above and foregoing statements are
within my knowledge true and correct.”
__________________________________________
Signature of Applicant or Applicant’s Designee
Subscribed and sworn before me the undersigned this _________ day of ______________________________,
20 ______.
___________________________________________
Notary Public or Deputy Clerk
ORDER
The above affidavit for exemption from jury duty was presented to the ___________ Court of Denton
County, Texas. The Court orders that the request for exemption should be
granted
denied .
If granted, the applicant will be exempt from jury duty in the justice, county and district courts of Denton
County, Texas for the period of time specified by the Physician’s Statement.
Signed this ____________ day of _______________________________________________, 20
___________________________________________
Presiding Judge
PHYSICIANS STATEMENT FOR MEDICAL EXEMPTION FROM JURY DUTY
Govt. code 62.109 (b). A person requesting an exemption under this section must submit to
the court an affidavit stating the person’s name and address and the reason for and the
duration of the requested exemption.
A person requesting an exemption due to a physical
or mental impairment must attach to the affidavit a statement from a physician.
Please have this statement completed, attach to the sworn affidavit and return affidavit along
with your jury summons/questionnaire and return to the Denton County Jury Services.
(Statements need to be submitted to our office at least 4-5 business days PRIOR to
your appearance date.)
(This section to be completed by the prospective juror)
Name of person applying for exemption: ______________________________________________
Address of person applying for exemption: ____________________________________________
______________________________________________________________________________
Juror No. ________________________
Date expected for service: _____________________
(**This section to be completed by the physician**)
Physicians Name: _______________________________________________________________
Physicians Address: ______________________________________________________________
______________________________________________________________________________
Physician’s Phone No. _____________________________________________
I do hereby certify that ____________________________________________________________
is under my care for a physical or mental impairment, and it is impossible or very difficult for him/her to
serve on a jury because of the specific condition(s) listed below (required):
Please check one of the following for the length of the exemption:
___________ Permanent
__________ Temporary
If this is a temporary medical exemption please give the length of time for the exemption.
____________________________
Signed this ____________ day of _____________________________, 20__________.
_____________________________________________
Signature of Physician
Sherri Adelstein, District Clerk
Denton County Jury Services
1450 E McKinney, Denton TX 76209
P O Box 2146, Denton TX 76202
940-349-2230
FAX: 940-349-2231
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