"Juror Excusal or Postponement Request Form"

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Return To:
[State Seal Here]
No later than 10 days before the
requested appearance date
This Space for Notary Office Use Only
Juror Excusal or Postponement Request
Juror Name:
Date:
Juror No.:
Case No.:
Court Location:
Appearance Date:
Excusal Request Due To:
(Please Check All the Boxes That Apply)
I am not a United States Citizen
I am currently being convicted of a felony
I am over the age of 70
I am a convicted felon w/o the return of my civil rights
I am under the age of 18
I am currently involved in another trial
I am pregnant
I have served as a juror in the past 24 months
I no longer live in this county
I cannot read or understand the English language
I am traveling abroad for more than 1 year
I am on active duty in the military
I am physically/medically incapable
I am an on-duty police officer
Elaboration/Details:
Postponement Request Due To:
(Please Check All the Boxes That Apply)
I am traveling at that time
I am caring for an ill friend/relative
I have business to attend to at that time
I am temporarily physically/medically incapable
I am a student and have exams at that time
I received my summons late
Elaboration/Details:
Requested Postponement Until:
I, the juror, hereby swear that the preceding information is correct and true to the best of my
knowledge. I understand that if I do not receive an excusal or postponement that I am
expected to arrive in court on the date requested.
Signature:
Date:
For Clerical Use Only
Juror Is:
Excused Due to:
Postponed Until:
Not Excused
Signature:
Date:
Return To:
[State Seal Here]
No later than 10 days before the
requested appearance date
This Space for Notary Office Use Only
Juror Excusal or Postponement Request
Juror Name:
Date:
Juror No.:
Case No.:
Court Location:
Appearance Date:
Excusal Request Due To:
(Please Check All the Boxes That Apply)
I am not a United States Citizen
I am currently being convicted of a felony
I am over the age of 70
I am a convicted felon w/o the return of my civil rights
I am under the age of 18
I am currently involved in another trial
I am pregnant
I have served as a juror in the past 24 months
I no longer live in this county
I cannot read or understand the English language
I am traveling abroad for more than 1 year
I am on active duty in the military
I am physically/medically incapable
I am an on-duty police officer
Elaboration/Details:
Postponement Request Due To:
(Please Check All the Boxes That Apply)
I am traveling at that time
I am caring for an ill friend/relative
I have business to attend to at that time
I am temporarily physically/medically incapable
I am a student and have exams at that time
I received my summons late
Elaboration/Details:
Requested Postponement Until:
I, the juror, hereby swear that the preceding information is correct and true to the best of my
knowledge. I understand that if I do not receive an excusal or postponement that I am
expected to arrive in court on the date requested.
Signature:
Date:
For Clerical Use Only
Juror Is:
Excused Due to:
Postponed Until:
Not Excused
Signature:
Date: