By submitting this form, I hereby swear or affirm to the Circuit Court that the matters and facts set forth herein are true and correct to the best of my knowledge.
If claiming the non-resident exemption, you must contact the Warren County Circuit Clerk and be removed from the voting rolls.
If claiming this exemption, your treating physician must email (firstname.lastname@example.org) or fax (601.630.8033) a medical excuse.
Financial Hardship ExemptionsJury service would cause undue or extreme financial hardship to myself. Jury service would cause similar hardship to a person under my care or supervision.
11a. I would be required to abandon a person under my personal care or supervision due to the impossibility of obtaining an appropriate substitute.
11b. I would incur costs that would have a substantial adverse impact on my ability to pay for my necessary daily living expenses or for those whom I provide the principal means of support.
IMPORTANT: In the box below, describe your hardship in detail, place of employment, an estimate of funds you will lose by serving, and number of dependents. YOU CANNOT RECEIVE THIS EXEMPTION WITHOUT DETAILS.
IF CLAIMING A COVID19 EXEMPTION, DESCRIBE YOUR SITUATION IN THE BOX BELOW USING THE OPTIONS GIVEN. YOU CANNOT RECEIVE THIS EXEMPTION WITHOUT A DETAILED EXPLANATION.12a. Schools or daycares are closed so I need to care for my children.
12b. I have traveled internationally within the last fourteen (14) days.12c. I have been in close contact with someone with a confirmed case of COVID-19 within the past 14 days.
12d. Myself or a member of my family falls into the category identified by the CDC as being high-risk for serious complications from the virus, including:
1.) Pregnant woman,2.) Persons with compromised immune systems due to cancer, HIV, history of organ transplant or other medical conditions,3.) Persons less than 60 years of age with underlying chronic conditions, or
4.) Persons over 60
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