Excusal Form



Please provide the following information



LAST NAME:

FIRST NAME:

REPORT DATE:

JUROR NUMBER:

HOME TELEPHONE:

BUSINESS TELEPHONE:

E-MAIL ADDRESS:



DISQUALIFICATION



Under Florida Statutes, you may not serve on a jury for the reasons listed below. Please indicate if you:

EXCUSAL



A citizen is NOT automatically disqualified from jury service for the reasons listed below, but may request to be excused for any of the following reasons:

A pregnant woman 04pregnant

Any person over 70 years of age 0670yoa

A person who has reported as a prospective juror for jury service within one (1) year from the prospective service month

Cases of extreme hardship (e.g. extended absence from the county)

A parent not employed full time, and having custody of a child under six (6) years of age

A care giver of a person with a mental or physical infirmity

A law enforcement officer 10leo

An individual with significant physical or mental infirmity



YOUR EXCUSE MUST BE APPROVED BY A JUDGE. PLEASE EXPLAIN THE REASON YOU ARE REQUESTING TO BE EXCUSED (100 words or less)

Reasonable effort will be made to notify you if your request has been approved or denied. However, if you do not receive written or telephone communication from this office, you must inquire three days prior to your report date as to your request or report on the assigned date of this summons.