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IN THE SUPERIOR COURT OF GORDON COUNTY STATE OF GEORGIA (REQUEST TO BE EXCUSED/DEFERRED FROM JURY DUTY) AFFIDAVIT OF JUROR Affiant is aware this affidavit is made so the Gordon County Superior Court may rely on same in determining eligibility for deferral/excusal from jury service pursuant to O.C.G.A. 15-12-1. I, having been summoned for Jury Duty for the week of hereby request to be excused/deferred from jury service due to the following: (Please Circle) I currently reside outside of Gordon County (Attach copy of Driver’s License or mailing with current address) I am a convicted felon any my civil rights have not been restored. I was convicted on (Please attach copy of sentence) I am not a citizen of the United States (Attach a copy of GA ID and Resident Alien ID) The person named in this summons is deceased (Indicate name and relationship of person completing form and the date of I am 70 years of age or older. My date of birth is I am a full-time student (Attach Student ID or course hours) I am the primary care giver having active care and custody of a child six years of age or younger. I am the primary unpaid caregiver for a person over the age of six years with such physical or cognitive limitation (Physician’s certificate required) I am the primary teacher in a home-school study program. I or my spouse (circle one) is on ordered military duty as follows:(Please attach a copy of military ID (O.C.G.A.§15-12-1.1(c)(2)). I am physically/mentally (circle one) unable to serve as juror (Physician’s Certificate required) I have served as a juror within the last six months I will be engaged in work necessary to the public health, safety or good order, as follows (May be deferred but not permanently excused) For other good I CERTIFY UNDER PEALTY OF LAW THAT THE ABOVE MARKED STATEMENT IS TRUE AND CORRECT. THIS OF NOTARY PUBLIC (Affix seal and Expiration Date) JUROR NAME JUROR PHONE NUMBER Having considered the above affidavit, the Petitioner shall be: _____Excused from jury service Deferred from jury service until the next term. Only ONE deferment shall be granted and Petitioner must report for service _____Required to report at the date and time listed on the jury summons. So ORDERED, this Clerk of Superior Court ---PAGE BREAK---