PASCOCLERK.COM - Jury Excusal, Disqualfication Form

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Please provide the following information as it appears on your jury summons.

Fields marked with a single asterisk (*) are required to be completed. Fields marked with a double asterisk (**) one or more must be completed. Please complete other areas as needed.

Please submit your request for excusal as soon as possible prior to your reporting date.

*LAST NAME:

*FIRST NAME:

*REPORT DATE:
mm/dd/yyyy

*JUDGE'S NAME:

*JUROR ID NUMBER:

**HOME TELEPHONE:
(999)123-4567

**BUSINESS TELEPHONE:
(999)123-4567

**E-MAIL ADDRESS:

MANDATORY EXEMPTIONS

You cannot serve if you qualify for any of the mandatory exemptions. Please indicate if you are:

Convicted of a felony, civil rights not restored

No longer reside in Pasco County, my new address is:

Not a U.S. citizen or legal resident of Florida

Served as a juror in Pasco County within 1 year.
Date served:

Under prosecution for any crime

OPTIONAL EXEMPTIONS

A citizen is NOT automatically disqualified from jury service for the reasons listed below. If you qualify for any reason listed below, check the reason that is applicable. You will receive a reply only if you are not excused.

Expectant mother

Full time law enforcement officer/investigative officer

Full time student attending school at: NAME OF SCHOOL

I wish to be excused for medical reasons - MUST SUBMIT DOCTOR'S STATEMENT WITH ORIGINAL SUMMONS BY MAIL

You are a parent not employed full time with custody of a child under age 6

Person 70 years of age or over. Date of birth is:
One time exemption
Permanent exemption

I am responsible for the care of someone who is incapable of caring for himself/herself.

If none of the above apply to your circumstance, YOUR EXCUSE MUST BE APPROVED BY A JUDGE. PLEASE EXPLAIN THE REASON YOU ARE REQUESTING TO BE EXCUSED (100 words or less).

You will receive a reply ONLY if you are NOT excused.

EXCUSALS - Deceased, Military, Other

I wish an excusal for the following reason(s):

By clicking the Submit Entry button, you are acknowledging that the above statements are true to the best of your knowlege and belief.

Quality Service ... Nothing Less

� 2004 Pasco County Clerk of the Circuit Court.