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IN THE SUPERIOR COURT BLAIRSVILLE, UNION COUNTY, GEORGIA AFFIDAVIT Personally appeared before me, the undersigned officer, duly authorized to administer under oath states as follows: Patient, is currently being treated by me for In my medical opinion said patient is permanently disabled and should not be considered for jury service, now or in the future. OR Patient, is currently being treated by me for The expected recovery date is could be considered for jury service at that time. PHYSICIAN Sworn and subscribed before me this of Notary Public My commission expires: I hereby swear that the above information provided by my doctor is true and correct. PROSPECTIVE JUROR’S SIGNATURE Date of jury service Juror ---PAGE BREAK--- PLEASE NOTE ENCLOSED YOU WILL FIND A MEDICAL AFFIDAVIT FOR YOUR PHYSICIAN TO COMPLETE. HE / SHE WILL NEED TO SPECIFY IF YOU ARE PERMANENTLY DISABLED OR IF YOU CAN BE RESCHEDULED WITHIN A SPECIFIC PERIOD OF TIME. THE LAW STATES THAT YOU MUST BE PERMANENTLY PHYSICALLY AND / OR MENTALLY DISABLED IN ORDER TO BE EXCUSED FROM JURY SERVICE AND THIS MUST BE PROPERLY DOCUMENTED. PLEASE HAVE YOUR DOCTOR COMPLETE THE ENCLOSED FORM AND MAIL BACK TO THIS OFFICE AS SOON AS POSSIBLE. MAIL TO: JUDY ODOM CLERK OF SUPERIOR COURT 65 COURTHOUSE STREET BLAIRSVILLE, GEORGIA 30512