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AFFIDAVIT OF JUROR RESIDENCY/ NAME/ADDRESS/TELEPHONE CHANGE GEORGIA UNION COUNTY Juror Name Juror ID # Juror Summons # Juror Date Summoned to I hereby affirm, that I, have changed my residency name/address/telephone FROM: Old Name Old Address City/State/Zip County Old Telephone TO: New Name New Address City/State/Zip County New Telephone Date of Birth Social Security Number I further certify that I do / do not (circle one) maintain or claim Union County as my principal residence. This day of Sworn to and Subscribed JUROR SIGNATURE before me this day of 20___ PRINTED JUROR NAME Notary Public