Affidavit For Exemption From Jury Duty For Physical Or Mental Impairment

AFFIDAVIT FOR EXEMPTION FROM JURY DUTY FOR PHYSICAL OR MENTAL IMPAIRMENT Government Code Section 62.109 allows for a permanent or temporary exemption from jury service based upon a physical or mental impairment. The exemption may only be granted by court order once an affidavit and physician's statement is received from the prospective juror. Please complete the affidavit and physician's statement and mail or fax them to Jury Services for submission to the Court. You will be notified if your request is granted or denied. Govt. Code 62.109(b) A person requesting an exemption under this section must submit to the court an affidavit stating the person's name and address and the reason for and the duration of the requested exemption.... Applicant's Name: ___________________________________________ Juror No.: _____________________ Applicant's Full Address: ____________________________________________________________________ __________________________________________________________________________________________ Date of Birth: _____________________ Daytime phone: ___________________________________________ Evening Phone: ____________________________ email: __________________________________________ Exemption requested: (Please check one) PERMANENT TEMPORARY Applicant requests exemption for the following reason: ___________________________________________ _________________________________________________________________________________________ Applicant states: "I am aware that jury service is not necessarily physically difficult, however, as a direct result of my physical or mental impairment, it is impossible or very difficult for me to serve on a jury." A physician's statement MUST be attached to this affidavit. The name and address of the physician is: Name: _______________________________________________________________________ Street/ PO Box: ______________________________________________________________________ City, State, Zip: ______________________________________________________________________ PLEASE NOTE THE FOLLOWING 1. The affidavit must be notarized and returned to: Hays County District Clerk, 712 S. Stagecoach Trail, Suite 2211, San Marcos, TX 78666 . 2. An applicant may request that the exemption be withdrawn by filing a signed request for withdrawal with Jury Services. STATE OF TEXAS COUNTY OF HAYS "I _______________________________________, on my oath state the above and foregoing statements are within my knowledge true and correct." __________________________________________ Subscribed and sworn before me the undersigned this _________ day of ______________________________, 20 ______. ___________________________________________ Notary Public or Deputy Clerk Signature of Applicant or Applicant's Designee (AS SHOWN ON EITHER VOTER REGISTRATION OR TEXAS DRIVER LICENSE) ORDER The above affidavit for exemption from jury duty was presented to the _________ District Court of Hays County, Texas. The Court orders that it should be granted denied as requested and that the applicant be exempted from jury duty in the justice, county and district courts of Hays County, Texas for the period of time specified by the Physicians Statement. Signed this ____________ day of _______________________________________________, 20______. ___________________________________________ Presiding Judge American LegalNet, Inc. www.FormsWorkFlow.com PHYSICIANS STATEMENT FOR MEDICAL EXEMPTION FROM JURY DUTY Govt. code 62.109 (b). A person requesting an exemption under this section must submit to the court an affidavit stating the person's name and address and the reason for and the duration of the requested exemption. A person requesting an exemption due to a physical or mental impairment must attach to the affidavit a statement from a physician. Please have this statement completed, attach to the sworn affidavit and return to the Hays County District Clerk. (This section to be completed by the prospective juror) Name of person applying for exemption: ______________________________________________ Address of person applying for exemption: ____________________________________________ ______________________________________________________________________________ Juror No. ________________________ Date expected for service: _____________________ (This section to be completed by the physician) Physicians Name: _______________________________________________________________ Physicians Address: ______________________________________________________________ ______________________________________________________________________________ Physician's Phone No. _____________________________________________ I do hereby certify that ____________________________________________________________ is under my care for a physical or mental impairment, and it is impossible or very difficult for him/her to serve on a jury because:_____________________________________________________________ Please check one of the following for the length of the exemption: ___________ Permanent __________ Temporary If this is a temporary medical exemption please give the length of time for the exemption. ____________________________ Signed this ____________ day of _____________________________, 20__________. _____________________________________________ Signature of Physician Beverly Crumley, District Clerk 712 S. Stagecoach Trail, Suite 2211 San Marcos, Texas 78666 Phone: 512-393-7660 FAX: 512-393-7674 American LegalNet, Inc. www.FormsWorkFlow.com