Full Text
IN THE SUPERIOR COURT OF WASHINGTON COUNTY STATE OF GEORGIA AFFIDAVIT OF JUROR JUROR SUMMONS NUMBER: PERSONALLY APPEARING before the undersigned officer duly authorized to administer oaths, came (PLEASE PRINT NAME), who on oath says, I have been summoned for jury duty the week of and hereby request to be excused/deferred from jury service due to the following reason: [Mark One] (THIS FORM MUST BE RETURNED 10 DAYS PRIOR TO THE COURT DATE) 1. I no longer reside in Washington County. My physical residence is: (Attach copy of Driver’s license or Voter’s Registration card reflecting your current residence.) 2. I am a convicted felon and my civil rights have not been restored. I was convicted on in County/State. 3. I am not a citizen of the United States. (Attach copy of I.D.) 4. The person named on this summons is deceased. (Indicate name and relationship of person completing form and the date of death. Include a contact phone number. 5. I am 70 years of age or older with a date of birth of and request permanent removal from the jury list of Washington County. (O.C.G.A. §15-12-1.1(b) 6. I am a fulltime student enrolled and taking classes or exams on the dates indicated in my jury summons. My expected date of graduation is (Please attach student I.D.) (O.C.G.A. §15-12-1.1(a)(2)). 7. I am the primary caregiver having active care and custody of a child six years of age or younger and have no reasonably available alternative child care (O.C.G.A. §15-12-1.1(a)(3)). 8. I am the primary unpaid caregiver for a person over the age of six with such physical or cognitive limitations. (Physician’s certificate required.) (O.C.G.A. §15-12-1.1(a)(5)). 9. I am a primary teacher in a home school program, as defined by O.C.G.A. 20-2-690(C); with no reasonable alternative arrangements for continuing the home school program. (Please attach a copy of your Annual Declaration of Intent to Utilize a Home School Study Program (O.C.G.A. §15-12-1.1(a)(4)). 10. I am ordered and/or my spouse (Circle One) is ordered on active military duty as follows: 11. Other (Explain) *If you complete this section, you must contact the Clerk’s Office at (478) 552-3186 to discuss your reason for exemption prior to submitting this Affidavit: I CERTIFY UNDER PENALTY OF LAW THAT THE ABOVE MARKED STATEMENT IS TRUE AND CORRECT. Sworn & subscribed before me This day of SIGNATURE OF JUROR Notary Public or Clerk of Superior Court Phone Number of Juror My Commission Expires: PHYSICIAN’S CERTIFICATE 1. The person whose name appears on the front of this summons is not able to serve as a juror. physically mentally (check One) This is a temporary condition This is a permanent condition and the person should be INACTIVATED from being chosen as a trial or grand juror. Doctor’s Signature Doctor’s Printed Name If you complete this form, please call (478) 552-3186 to verify that you have been excused. Return to Megan Cramer, Clerk of Superior Court P.O. Box 231, Sandersville, GA 31082 Fax: (478) 553-9969; Email: